Use of a 3D-Printed Patient-Specific Surgical Jig and Ready-Made Total Sacral Endoprosthesis for Total Sacrectomy and Reconstruction

Objective. In the present study, the authors aimed to optimize the workflow of utilizing a 3D printing technique during surgical treatment for malignant sacral tumors, mainly on preparation of patient-specific surgical jigs and ready-made 3D-printed total sacral endoprosthesis. Methods. Three patients with a malignant sacral tumor received total sacrectomy with preoperative design of a patient-specific 3D-printed cutting jig and endoprosthetic reconstruction. Size of ready-made 3D-printed endoprosthesis was determined based on preoperative images, planned surgical margin, and size of the endoprosthesis. A patient-specific cutting jig was designed with a bilateral cutting slot matching the bilateral planes of the implant precisely. The tumor was removed en bloc through a single posterior approach only, being followed by reconstruction with ready-made total sacral endoprosthesis. Results. The mean time for preoperative design and manufacture of the surgical jig was 6.3 days. Surgical jigs were successfully used during surgery and facilitated the osteotomy. The mean operation time was 177 minutes (range 150-190 minutes). The mean blood loss was 3733 ml (range 3600-4000 ml). R0 resections were achieved in all the three cases proven by pathology. Evaluation of osteotomy accuracy was conducted by comparing preoperative plans and postoperative CT scans. The mean osteotomy deviation was 2.1 mm (range 0-4 mm), and mean angle deviation of osteotomy was 3.2° (range 0-10°). At a mean follow-up of 18.7 months, no local recurrence was observed. One patient had lung metastasis 15 months after surgery. Two patients were alive with no evidence of the disease. Conclusions. The patient-specific surgical jig and ready-made 3D-printed total sacral endoprosthesis can shorten the surgical preparation time preoperatively, facilitating accurate osteotomy and efficient reconstruction intraoperatively. The workflow seems to be feasible and practical.

Osteosynthesis of Common Acetabular Fractures Operated on Through a Single Posterior (Kocher-Langenbeck) Approach with or without Trochanteric Flip Osteotomy. A Case Series

Background. The Kocher-Langenbeck approach is recommended in the majority of common posterior acetabular injuries. Trochanteric osteotomy can be used to extend the exposure of the Kocher-Langenbeck approach superiorly and anteriorly. We evaluated the functional outcome of common acetabular fractures operated on through the Kocher-Langenbeck approach with or without trochanteric flip osteotomy. Material and methods. This prospective study enrolled 42 patients with posterior wall, posterior column, transverse, posterior wall with posterior column, transverse with posterior wall and both column acetabular fractures. The Kocher-Langenbeck approach was used in 35 patients and trochanteric flip osteotomy was done in 7 patients. The radiological outcome was evaluated by Matta’s criteria and the functional outcome was evaluated using modified Merle d'Aubigné and Postel criteria. Results. D’Aubigne Postel scores at the final follow-up were excellent in 12 patients, good in 18, fair in 8 and poor in 4. Thirty-seven patients had congruent reduction (anatomical in 29, imperfect in 8) and 5 patients had non-congruent reduction on radiographs as per Matta’s criteria. Radiographic congruity (88.09%, 37 out of 42 cases) correlated fairly well with the functional outcome (excellent or good functional outcome in 71.4%, 30 out of 42 cases). The complications included traumatic nerve palsy (3 cases), iatrogenic nerve palsy (2 cases), deep venous thrombosis (2 cases), wound infection (3 cases), non-congruent reduction (5 cases), 8 cases of osteoarthritis of hip, 2 cases of avascular necrosis of femoral head and 3 cases of heterotrophic ossification. Conclusions. 1. Surgical treatment of common acetabular fractures with major posterior involvement can be attempted via a single posterior approach (Kocher-Langen­beck with or without trochanteric flip osteo­tomy) and leads to good-to-excellent results in a majority of the cases. 2. It is superior to conservative management, which has been found to be accompanied by a much higher rate of complications. 3. A thorough study of the pre-opera­tive radiographs, Judet’s views and 3D-reconstructed CT images helps in classifying the fracture and thereby assigning or not assigning it for the posterior approach.

Odontoid Resorption After Posterior Occipitocervical Fusion in Rheumatoid Basilar Invagination

Background Context: Inflammatory arthritis of the cervical spine is common and begins early after the onset of rheumatoid arthritis. Atlantoaxial instability is the most common pattern followed by cranial settling or basilar invagination, with subaxial subluxation being least common. Vertical migration of the odontoid (basilar invagination) poses an increased risk of sudden death from compression of the brain stem. A combination of transoral decompression and posterior occipitocervical fusion has been described, although a single posterior approach stabilization may suffice and avoid the associated comorbidities with an anterior/posterior surgery in a high-risk rheumatoid patient. Purpose: To report a case of odontoid resorption and cervicomedullary angle improvement after occipitocervical fusion. Study Design: A retrospective case report. Methods: Radiographic analysis. Results: After posterior occipitocervical fusion alone for basilar invagination there was a reduction of cervicomedullary angle to 127 degrees at 3 years follow up. This was improved from an initial 115 degrees through odontoid remodeling. Conclusions: Basilar invagination treated with posterior alone occipitocervical stabilization may suffice in providing stability and long term decompression of the cervicomedullary junction through resorption and remodeling of the odontoid. This case study supports the viability of avoiding a transoral resection for an irreducible severely migrated odontoid.

Debridement and corpectomy via single posterior approach to treat pyogenic spondylitis after vertebral augmentation

Background Infection after vertebral augmentation (VA) often limits the daily activities of patients and even threatens their life. The operation may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability. This study aimed to investigate the clinical efficacy of the treatment of pyogenic spondylitis after vertebral augmentation (PSVA) with Single posterior debridement, vertebral body resection, and intervertebral bone graft fusion and internal fixation (sPVRIF). Methods The study was performed on 19 patients with PSVA who underwent VA at 4 hospitals in the region between January 2010 and July 2020. Nineteen patients were included. Among them, 16 patients underwent sPVRIF to treat the PSVA. Results A total of 2267 patients underwent VA at 4 hospitals in the region. Of the 19 patients with postoperative PSVA, suppurative spondylitis was misdiagnosed as an osteoporotic vertebral fracture(OVF) in 4 patients and they underwent VA. Besides osteoporosis, 18 patients had other comorbidities. The average interval between the first surgery and the diagnosis of PSVA was 96.4 days. Of the 19 patients, 16 received surgical treatment. The surgical time was 175.0±16.8 min, and the intraoperative blood loss was 465.6±166.0 mL. Pathogenic microorganisms were cultured in 12 patients. Conclusion PSVA is a severe complication that can even threaten the life of the patients. sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability.

Comparison between single anterior and single posterior approaches of debridement interbody fusion and fixation for the treatment of mono-segment lumbar spine tuberculosis

Purpose To compare the efficacy of single anterior and single posterior approach of debridement, interbody fusion, and fixation for the treatment of mono-segment lumbar spine tuberculosis (TB) patients. Methods Eighty-seven patients with mono-segment lumbar TB who underwent debridement, interbody fusion, and fixation through either single anterior (Group A) or single posterior approach (Group B) from January 2007 to January 2017 were enrolled in this study. The duration of the operation, blood loss, complication rate, visual analog scale (VAS), Oswestry disability index (ODI), Frankel scale, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), kyphosis angle, correction rate, correction loss, and time taken for bone graft fusion were compared between the groups. Results The average period of follow-up was 34.3 ± 9.5 months (24–56 months). No significant differences were observed between patients in Group A and patients in Group B in terms of gender, age, body mass index (BMI), duration of illness and preoperative evaluative indices (P > 0.05). The mean operation time and blood loss was significantly higher in Group A (P = 0.000), along with a slightly higher rate of complications compared with Group B (P = 0.848). The VAS, ODI and Frankel scale scores showed significant improvement in both groups (P = 0.000), along with the ESR, CRP and kyphosis indices (P = 0.000), which were similar in both groups at the final follow-up. Conclusion Both single anterior and single posterior approaches of debridement, interbody fusion and fixation are effective for mono-segment lumbar TB patients, although the single posterior approach is of a shorter duration and results in less blood loss.

Debridement and Corpectomy Via Single Posterior Approach to Treat Pyogenic Spondylitis after Vertebral Augmentation

Background Infection after VA often limits the daily activities of patients and even threatens their life. Operation has become an indispensable choice for such patients. sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability. This study aimed to investigate the clinical efficacy of treatment of PSVA with sPVRIF. Methods The study was performed on 19 patients with PSVA who underwent VA at 4 hospitals in the region between January 2010 and July 2020. Nineteen patients were included. Among them, 16 patients underwent sPVRIF to treat the PSVA.Results A total of 2267 patients underwent VA at 4 hospitals in the region. Of the 19 patients with postoperative PSVA, suppurative spondylitis was misdiagnosed as an osteoporotic vertebral fracture in 4 patients and they underwent VA. Besides osteoporosis, 18 patients had other comorbidities.The average interval between the first surgery and the diagnosis of PSVA was 96.4 days. Of the 19 patients, 16 received surgical treatment.Among the patients undergoing surgery, one died of refractory septic shock after the surgery, and one died of prostate cancer. The surgical time was 175.0±16.8min, and the intraoperative blood loss was 465.6±166.0 mL.Fourteen patients recovered from the infection.Pathogenic microorganisms were cultured in 12 patients. Conclusion PSVA is an extremely serious complication that can even threaten the life of the patients.sPVRIF may be one of the effective treatments if the patient suffers from intolerable severe pain, neurological deficits, and damage to spinal stability.

Hemivertebrectomy of L5 in Grade 2 Chondrosarcoma: Is a Single Posterior Approach with No Nerve Root Sacrifice Possible? A Case Report

En-bloc resection of spine tumors is difficult to achieve compared to extremities tumors for anatomical reason. Several surgical techniques have been described, such as combined multiple surgical approaches or an enlarged single posterior approach. These demanding strategies correlate with high rate of intraoperative/postoperative complications. The current case is about a patient treated with a single posterior-lateral surgical approach to perform hemivertebrectomy of L5 for a single grade 2 chondrosarcoma metastasis (WBB 2-5/b-c). Usually, L5 hemivertebrectomy requires a combined surgical approach to preserve L5 root. The final solution was to perform a T-shape skin incision: a longitudinal branch centered on the vertebral spine and a transverse branch on the iliac crest. This approach allowed osteotomy of the ipsilateral iliac crest, achieving sufficient view to preserve L5 root and vessels anteriorly; the same osteotomy was used to create a bone autograft to reconstruct the residual part of L5. Finally, cryotherapy was used in order to increase the adequacy of surgical margins. A L3-S1 arthrodesis is assembled to achieve stability of the system. Surgical time was 5 hours, no nerve roots have been sacrificed nor any other intraoperative complications occurred. This surgical technique had never been described before in literature.