Evaluation of short-term effects on 3D printing patient-matched artificial vertebral body in clinical research and application / 中华骨科杂志

Objective:To evaluate the short-term efficacy and safety of 3D printing patient-matched artificial vertebral body in clinical research and application.Methods:A total of 12 patients with spinal tumors were enrolled 7 males (58.33%) and 5 females (41.67%), aged from 18 to 65 years old in The First Affiliated Hospital of Air Force military Medical University (hereinafter referred to as Xijing Hospital) and Peking University people's Hospital from September 2021 to July 2022. The spinal vertebra defect were restored by using 3D printing patient-matched artificial vertebral body after tumor resection. All patients who accepted TES and 3D printing patient-matched artificial vertebral body implantation were included according to the inclusion and exclusion criteria. The bone interface fusion was evaluated by the imaging fusion criteria of Brantigan and Steffee at 3 and 6 months after operation, the curative effect was evaluated by comparing Japanese Orthopaedic Association (JOA) score at 3 and 6 months after operation, visual analogue scale (VAS) 3 months after operation and intervertebral height at 3 and 6 months after operation with those before operation, and the safety was evaluated by adverse event recording.Results:All 12 patients completed the operation successfully, and the operation sites were thoracic vertebrae in 6 cases (50%), thoracolumbar in 3 cases (25%) and lumbar vertebrae in 3 cases (25%). All patients were followed up. The mean follow-up time was 23.92±3.23 months (range, 19-29 months). No tumor recurrence or metastasis was observed during this period. All patients were followed up at 15 days, 3 months and 6 months after operation. During the 6-month follow-up, X ray results showed that interface of bone and the vertebral body were fused in all of the 12 patients, and the effective rate of fusion was 100%. The 95% confidence interval is calculated to be (75.6%-100%). Six months after operation, the improvement rate of JOA score was excellent in 10 cases, good in 1 case, poor in 1 case, and the excellent and good rate was 91.66%. The preoperative VAS score was 4.08 ±2.47, and during the 3-month follow-up, the VAS score was improved to 1.83 ±1.59. Compared with the preoperative VAS score, the difference was statistically significant ( t=2.635, P=0.023). The intervertebral height before operation, 15 days after operation, 3 months after operation and 6 months after operation were 32.75 (25.94, 68.20), 41.09 (30.55, 70.20), 40.70 (30.23, 67.83) and 40.74 (30.23, 67.08), respectively, and there was no statistically significant difference (χ 2=0.768, P=0.857). No implant-related adverse events occurred after operation. Conclusion:The 3D printing patient-matched artificial vertebral body used in this study has satisfactory short-term efficacy and safety in the reconstruction of spinal stability after spinal tumor resection.

Efficacy of 3D-printed segmental tumor prosthesis for reconstruction of bone defects after resection of weight-bearing long bone tumors in the lower extremity / 中华骨科杂志

Objective:To investigate the efficacy of 3D-printed segmental tumor prosthesis for reconstruction of bone defects after resection of weight-bearing long bone tumors in the lower extremity.Methods:A total of 71 patients who received 3D-printed segmental metal tumor prosthesis for reconstruction of bone defects from August 2015 to August 2021 at the Musculoskeletal Tumor Center of Peking University People's Hospital were retrospectively analyzed. There were 40 males and 31 females, aged 23.08±18.52 years (range, 10-63 years). Tumor types: 49 cases of osteosarcoma, 9 cases of Ewing sarcoma, 3 cases of chondrosarcoma, 3 cases of synovial sarcoma, 2 cases of pleomorphic undifferentiated sarcoma, 2 cases of rhabdomyosarcoma, 2 cases of bone metastasis, and 1 case of low-grade malignant tumor of mesenchymal origin. Ennecking stage of bone tumor: 19 cases of stage III, 52 cases of stage IIb. Tumor location: femur 43 cases, tibia 28 cases. Operative time, intraoperative bleeding, patient survival and postoperative complications were recorded. Kaplan-Meier curves for prosthetic survival were plotted. The osseointegration at the prothesis-bone interface was determined by combination of clinical presentation and imaging. Limb function scores were evaluated using the Musculoskeletal Tumor Society (MSTS) 93 function score.Results:All 71 patients successfully completed the operation and were followed up for 24.4±13.2 months (range, 6.6-65.4 months). At the last follow-up, 50 patients survived without disease, 12 survived with the disease, and the remaining 9 cases died with disease. A total of 11 cases showed prosthesis failure, including 1 case of aseptic loosening, 3 cases of screw breakage or periprosthetic fracture, 1 case of periprosthetic infection, and 6 cases of tumor progression involving the prosthesis. The Kaplan-Meier curve showed that the 1-year, 3-year and 5-year survival rates of prosthesis were 94.2%±2.8%, 86.1%±4.7% and 79.5%±9.2%, respectively. 62 patients received functional follow-up, and the MSTS93 functional score at the last follow-up was 23.95±5.03 points (range, 10-30 points), with an excellent rate of 90% (56/62). The score of femoral prosthesis was 24.63±4.97 points (range, 13-30 points) and the score of tibial prosthesis was 23.29±5.09 points (range, 10-29).Conclusion:3D-printed segmental tumor prosthesis for reconstruction of bone defect after resection of weight-bearing long bone tumors in the lower extremity has a relative high survival rate, a low incidence of prosthetic complications, and a good recovery of function, and it can be used as an option for the postoperative reconstruction of bone tumors in weight-bearing bones of the lower extremity.

Analysis of clinical outcomes in en bloc resection for spinal tumors / 中华骨科杂志

Objective:To assess the clinical outcome of patients with spinal tumors who received en bloc resection in our center and to provide theoretical basis for developing novel surgical technique in en bloc resection for spinal tumor.Methods:We retrospectively reviewed the clinical and follow-up data of 113 patients who received en bloc resection for spinal tumors in Musculoskeletal Tumor Center, Peking University People's Hospital from Jan. 2007 to Dec. 2021. There were 68 males and 45 females with an average age of 38.7±16.7 (10-79) years. Primary malignant spinal tumors, primary aggressive spinal tumors and solitary metastatic spinal tumors were diagnosed in 55, 27 and 31 patients, respectively. The surgeries were planned according to the surgical classification for en bloc resection for spinal tumors proposed by Boriani et al, which classified the en bloc resection for spinal tumor into 7 types. The general condition (gender, age, histological diagnosis, location of the lesion, number of involved vertebrae, pre-operative neurological function), surgical procedure (type of surgery, stage of surgery, reconstruction method for anterior structure, duration of surgery, intra-operative haemorrhage, surgical margin), peri- and post-operative complication (intra- and peri-operative complication, post-operative neurological function), and survival [overall survival (OS), recurrence-free survival (RFS) and implant survival (IS)] of patients were retrospectively analyzed.Results:All surgeries accomplished uneventfully except one intra-operative death owing to the haemorrhagic shock caused by injury of major blood vessel. Mean duration of surgery and volume of intra-operative haemorrhage was 517.6±267.4 min and 3802.7±3039.4 ml, respectively. R0 resection was achieved in 48 patients. Three patients died in peri-operative period. Intra- and peri-operative complications were identified in 44 patients (38.9%). 109 patients were followed up with a mean time of 39.4±35.2 months. 27 patients died during follow-up period. The average post-operative overall survival (OS) was 115.4[95% CI (97.9, 133.0)]months and the 5-year OS rate was 64.1%[95% CI (52.3%, 75.9%)]. In patients with primary malignant spinal tumors, the OS of patients with R2 resection was significantly poorer than that of patients with R0/R1 resection ( P=0.024); in patients with metastatic tumors, no difference of OS was observed in patients with different surgical margins ( P=0.612). There were 29 recurrences, and the mean RFS was 105.8 [95% CI (87.5, 124.1)] months. In patients with primary malignant and aggressive spinal tumors, the RFS of patients underwent R2 resection was significantly lower than that of patients underwent R0/R1 resection ( P=0.008, P=0.027); in patients with metastatic spinal tumors, no significant difference of RFS was found in patients with different surgical margin (P=0.707). Conclusion:Although en bloc resection for spinal tumors indicates high morbidity, it significantly improves the OS of patients with primary malignant spinal tumors and the local control of primary malignant and aggressive spinal tumors.

A meta-analysis of progressive pulmonary micro nodules in osteosarcoma / 中华骨科杂志

Objective:To identify the prevalence of pulmonary micro nodule (PMN) in osteosarcoma, investigate radiologic features of progressive PMN, and provide evidence for early diagnosis of pulmonary metastasis of osteosarcoma.Methods:Electronic articles published in PubMed, EMBASE, Web of Science and the Cochrane Library databases between January 1, 2000, and September 1, 2022, were searched and critically evaluated. The authors independently reviewed the abstracts and extracted data on the prevalence of PMN in osteosarcoma and radiologic features of progressive PMN. Seven high quality studies were finally included in the meta-analysis with evidence level III.Results:The pooled prevalence of PMN in osteosarcoma was 36.0%, 95% CI (14.6%, 57.3%). The pooled progressive rate of PMN was 52.5%, 95% CI (37.7%, 67.2%). As for a specific PMN, it was more likely to progress which had a larger Dmax, HR=2.40, 95% CI (1.06, 5.42), P=0.035. No significant difference was found in number, component, and border. Conclusion:PMN is quite common in patients with osteosarcoma. About half of the patients suffered the progression of PMN, and it is related to several risk factors.

Application of indocyanine green-based fluorescence imaging in bone and soft tissue tumors / 中华骨科杂志

Objective:To explore the role and value of indocyanine green (ICG) fluorescence imaging in the surgery of bone and soft tissue tumors.Methods:A total of 38 patients with bone and soft tissue tumors, including 17 males and 21 females, aged 36±21 years (range 5-75 years), who underwent resection with application of ICG-based NIR imaging were retrospectively analyzed. ICG was intravenously administrated at a dose of 2 mg/kg on the day before surgery. Intraoperative NIR imaging was performed to confirm the tumor fluorescence and to detect residual tumor after tumor resection. The NIR imaging was post hoc analyzed to explore the influence factor of tumor stain rate and SBR value.Results:Tumor staining with ICG was successful in 34 of the 38 patients, with an overall staining rate of 90%. The ICG tumor stain rate was not influenced by different pathology types, malignant or benign pathology, the reception of neoadjuvant chemotherapies or not, and the length of time between drug administration and surgery ( P>0.05). The median SBR of 34 patients with successful tumor staining was 2.9 (2.3, 5.7). Different pathological types, malignant or benign pathology, whether to receive neoadjuvant chemotherapy, preoperative ICG administration time, preoperative dose of denosumab administration in giant cell tumor of bone patients and tumor response to neoadjuvant chemotherapy had no significant effects on SBR ( P>0.05). After tumor resection, a total of 57 pieces of tissue with residual fluorescence signals were detected and resected under the fluorescence guidance, 30 of which were pathologically confirmed to contain residual tumor lesions, with an overall accuracy of 53%. The accuracy of intralesional resection was significantly higher than that of en bloc resection (71% vs. 16%, χ 2=15.51, P=0.000). Conclusion:A high percentage of bone and soft tissue tumors can be stained with ICG. The tumor stain of ICG was stable and not easily influenced by external factors. This technique was useful to detect residual tumors, especially after piecemeal resection.

Osteosarcoma with bone metastasis or pulmonary metastasis show distinct genomic manifestations / 中华骨科杂志

Objective:To investigate the genomic manifestation and pathogenesis of osteosarcoma with different relapse pattens, which were respectively initially presented with bone metastasis or pulmonary metastasis.Methods:From May 1, 2021 to October 1, 2021, 38 fresh tumor specimens and some paraffin-embedded specimens of high-grade osteosarcoma were collected in Peking University People's Hospital, including 29 males and 9 females, aged 19.6±2.2 years (range, 6-61 years). Among the 38 cases, 12 cases had initial bone metastasis (group A) and 26 cases had initial lung metastasis (group B), of which 15 cases (40%, 15/38) had paired specimens of primary and metastatic lesions. Based on Illumina NovaSeq 6000, we analyzed whole-exome sequencing (WES) as well as transcriptome for osteosarcoma with paired samples in different relapse patterns. During all their treatment courses, we also collected their paired samples to reveal these tumors' evolution. We sought to redefine disease subclassifications for osteosarcoma based on genetic alterations and correlate these genetic profiles with clinical treatment courses to elucidate potential evolving cladograms.Results:We found that osteosarcoma in group A mainly carried single-nucleotide variations (83%, 10/12), displaying higher tumor mutation burden [4.9 (2.8, 12.0) & 2.4 (1.4, 4.5), P=0.010] and neoantigen load [743.0 (316.5, 1,034.5) & 128.5 (49.0, 200.5), P=0.003], while those in group B mainly exhibit structural variants (58%, 15/26). The mutation spectrum showed that there was a significant difference in age-related gene imprinting 1 between the bone metastasis group and the lung metastasis group ( P=0.005). Samples were randomly selected from group A (3 patients) to investigate immunologic landscape by multiplex immunohistochemistry, from which we noticed tertiary lymphatic structure from one patient from group A. High conservation of reported genetic sequencing over time was found in their evolving cladograms. Conclusion:Osteosarcoma with mainly single-nucleotide variations other than structural variants might exhibit biological behavior predisposing toward bone metastases with older in age as well as better immunogenicity in tumor microenvironment.

Evaluation of utilizing cement-in-cement technique for endoprosthetic revision surgeries around the knee / 中华骨科杂志

Objective:To investigate the clinical efficacy of cement-in-cement (CiC) technique for endoprosthetic revision surgeries of noninfectious causes around the knee.Methods:All of 128 patients who had received cement-in-cement technique for endoprosthetic revision from February 2002 to August 2020 including 71 males and 57 females, whose mean age was 33.5±15.4 years (range, 8-77 years). 128 patients included 73 cases of osteosarcoma, 38 cases of giant cell tumors, 8 cases of undifferentiated sarcoma, 4 cases of chondrosarcoma, 2 cases of Ewing sarcoma, 2 cases of fibrosarcoma and 1 case of synovial sarcoma, with 105 cases in distal femur and 23 cases in proximal tibia. The failure mode classification included 64 cases of aseptic loosening, 47 cases of structure failure and 17 cases of tumor progression. 16 out of the 19 endoprosthese failure after the first cement-in-cement procedure received a second cement-in-cement procedure. The survival of revised prostheses, duration of the operation, the amount of blood loss, epidemiological data, complications and limb function were enrolled and statistical analyzed.Results:The mean follow-up from CiC revision was 127±33 months (range, 6-326 months). There were 25 (19.5%) complications for the first CiC procedure and 19 (14.8%) of the 25 complications lead to the protheses failure including 5 (3.9%) structure failure, 6 (4.7%) aseptic loosening, 2 (1.6%) tumor recurrence and 6 (4.7%) infection. The other 6 cases included 5 poor superficial wound healing and 1 patellar ligament rupture. All were recovered after debridement and tendon repair. The cumulative survival rates of first CiC procedure were 85.0%, 76.6% and 70.7% at 5, 10 and 15 years, respectively. Limb salvage rate was 97.7%. Sixteen of the 19 cases received a second CiC revision. The mean operative time (206±51 min vs. 258±41 min, t=3.18, P=0.399), blood loss (596±217.99 ml vs. 621±245.84 ml, t=0.30, P=0.926) and the median MSTS 93 score (26.38±2.47 vs. 25.06±2.11, t=1.61, P=0.376) of the first and second CiC procedure for the 16 cases were similar. Conclusion:CiC technique is a repeatable, conservative and viable option for endoprosthetic revision surgeries of noninfectious causes around the knee, with acceptable prosthetic survival rate, complication rate and limb function.

Physeal-sparing distal femur megaprothesis for skeletally immature patients with osteosarcoma / 中华骨科杂志

Objective:To evaluate the clinical outcome of a special physeal sparing knee prosthesis for pediatric distal femoral osteosarcoma regarding the functional outcome, retention of the growth potential of the proximal tibia, and postoperative complications.Methods:A retrospective study was conducted to review 37 pediatric patients with osteosarcoma of distal femur who were treated in a single musculuskeletal tumor center between August 2015 and January 2019. Among them, 21 were boys and 16 were girls, aged from 5 to 12 years at the time of operation, with an average age of 9.1±2.1 years and the height of 115 to 160 cm, with an average of 140±10 cm. Tumor resection of distal femur was performed and the bone defect was reconstructed by a special hinged knee prosthesis which can preserve the proximal tibial epiphyseal plate. Demographic data was recorded. Overall leg length and tibial length was assessed by full-length standing anteroposterior radiographs of bilateral lower extremity with the patella pointing anteriorly preoperativelly and postoperativelly at each follow up. And the growth potential of the affected proximal tibia was calculated by comparing with the preoperative length of tibia. Meanwhile, the functional outcome was assessed by using the Musculoskeletal Tumor Society (MSTS) system, and the postoperative complications were analysed.Results:All patients underwent the tumor resection and reconstruction operation successfully. The average operation duration was 143±41 minutes, ranging 90 to 250 minutes. The average intraoperative blood loss was 314±397 ml, ranging 30 to 2 200 ml. The patients were followed up for 24 to 64 months, averaging 42.3±12.1 months. The postoperative knee range of motion was 100-130 degrees, with an average of 115.6±7.2 degrees. The postoperative MSTS score was 23-30, with an average of 26.7±1.6. To the last follow-up, the limb length discrepancy of the lower limb was 1.3 to 10 cm, and the length of the tibia was shortened from 0 to 3.8 cm compared with the opposite side, with an average of 1.3±1.0 cm. The growth percentage of the proximal tibial epiphysis on the affected side was 30% to 100%, with an average of 70%±17%. Totally, 13 patients suffered postoperative complication, the overall incidence of complications was 35% (13/37), and prosthesis-related complications were 16% (6/37). Three patients with wound dehiscence were managed by debridement and antibiotics. Radiographs revealed femoral stem loosening in a single patient 3 years after the initial operation and then the prosthesis was converted to an adult tumor knee endoprosthesis. Two cases experienced breakage of the femoral stem at 30 and 33 months, respectively, due to an accidental injury. They received revision surgery, and a new femoral prosthesis component was replaced. One patient developed femoral stem breakage at 10 months after surgery due to fatigue fracture, which treated with revision surgery. Tumor recurrence occurred in 6 patients. Among them, tumor recurrence in soft tissue occurred in 4 patients, and treated with regional resection without further recurrence. The other 2 patients experienced tumor recurrence at the distal femoral site, and treated with resection and prosthetic revision.Conclusion:The physeal sparing pediatric knee prosthesis can preserve the growth potential of the proximal tibial epiphyseal plate with good postoperative function and low incidence of prosthesis complications. Therefore, it can be an alternativeespecially for skeletally immature patients with distal femur osteosarcoma.

Application of newly designed modular hinged ankle prosthesis in the reconstruction of defect after surgical treatment of malignant tumor at the distal tibia / 中华骨科杂志

Objective:To investigate the outcome of surgical treatment of malignant tumor at the distal tibial after reconstruction with modular hinged ankle prosthesis.Methods:The data of 9 patients with malignant tumor at the distal tibia at Musculoskeletal Tumor Center of PKUPH from June 2020 to November 2021 were analyzed retrospectively. They were male patients with age of 17 (14, 24) years (range 11-56 years). There were five tumors at the left sides and four at the right sides. There were eight patients with osteosarcoma who received the neo-chemotherapy. Among eight osteosarcomas, one was Enneking IIA and seven Enneking IIB. Furthermore, there was only one patient with renal carcinama and with solitary metastatic lesion at the distal tibia. After the resection of tumor at the distal tibia, talus cartilage was removed and talus component was fixed by lag screws. The proper tibia component was used to restore the defect of tibia and the reduction of tibia and talus components were performed. The following clinical data were collected: baseline demographic features, surgical and follow-up data. The baseline demographic features included gender, age, side, lung or/and other metastasis at initial diagnosis, Enneking stage or systematic progression for renal carcinama, histological type. The surgical data included: surgery time, blood loss, length of bone involved by the tumor, prosthesis type. Monitoring data was also recorded: complications (ankle pain when loading, talar collapse, component loosing, infection and wound dehiscence), local recurrence, pulmonary and systematic metastasis, radiological image and the function at the last follow-up (MSTS and VAS evaluation).Results:Among these nine patients, the average blood loss was 245.6±103.9 ml (range 100-400 ml) and the mean surgery time was 178.9±56.9 mins (range 120-300 min). No patient was lost during the follow-up period and the average follow-up was 21.4±5.6 months (range 12.5-27.2 months). The excision length of tibia was 14 (11, 17) cm (range 11-28 cm). There were one case with 2# prosthetic base, three cases with 3# and five cases with 4#. Five had cement fixation of prosthetic stem and four had the pressing fixation. No pulmonary and other organ metastasis occurred among eight patients with osteosarcoma and one patient with distal tibia matastasis of renal carcinama. One patient with OShad the local recurrence and received the resection. One sustained the deep infection after four months and received the removal of prosthesis and spacer implant. At the final follow-up, except one with deep infection and receiving the removal of prosthesis and spacer implant, eight patients were assessed for the function. The average MSTS was 97.1%±3.3% (range 93%-100%). The VAS of all patients was 0. One patient with prosthesis removal had no functional evaluation. At the final follow-up, all patients walked without crutch. No breakage and loosening of prosthetic stem, talar collapse, prosthetic sinking and ankle pain occurred at the final follow-up.Conclusion:The early satisfactory outcome can be obtained for patients with segmental defect after resection of malignant tumor at the distal tibia, who received the newly designed modular hinged ankle prosthesis. Meanwhile, it's worth promoting in the reconstruction of large segmental defect at the distal tibia.

Application of three-dimensional printed endoprosthesis for reconstruction after metaphysis-involved intercalary tumor resection / 中华骨科杂志

Objective:To describe the design, manufacture and use of three-dimensional (3D)-printed endoprosthesis for reconstruction after metaphysis-involved intercalary tumor resection and to evaluate its outcome.Methods:Forty-three patients who received metaphysis-involved intercalary tumor resection followed by 3D-printed endoprosthetic reconstruction in Musculoskeletal Tumor Center, Peking University People's Hospital between January 2018 and December 2021 were retrospectively reviewed. There were 25 males and 18 males with an average age of 20.1±15.2 years (range, 4-58 years). The pathological diagnosis included 24 cases of osteosarcomas, 6 cases of Ewing sarcomas, 5 cases of chondrosarcomas, 2 cases of pleomorphic undifferentiated sarcomas, 3 cases of soft-tissue sarcomas (liposarcoma, synovial sarcoma, malignant peripheral nerve sheath tumor for each) and 3 others (adamantinoma, recurrent aneurysmal bone cyst and recurrent osteofibrous dysplasia for each). The tumors located at femur in 25 patients (58%), including 14 lesions involving distal femoral metaphysis and 11 lesions involving both proximal and distal metaphysis; the tumors located at tibia in 11 patients (26%), including 4 lesions involving distal tibial metaphysis, 5 lesions involving proximal tibial metaphysis and 2 lesions involving both proximal and distal tibial metaphysis; the tumors located at humerus in 7 patients (16%), including 1 lesion involving distal humeral metaphysis, 3 lesions involving proximal humeral metaphysis and 3 lesions involving both proximal and distal humeral metaphysis. The endoprosthesis was designed in a semi-modular fashion and consisted of three parts: a diaphysis-fixing component, a semi-modular lap joint component, and a custom-made 3D-printed metaphysis-fixing component which was designed as two types with 3D-printed porous bone-contacting surfaces according to the osteotomy plane (Type I on meta-diaphyseal region, Type II on meta-epiphyseal region). The functional outcome was assessed using Musculoskeletal Tumor Society (MSTS) 93 system.Results:All surgeries were accomplished sucessfully. The median resection length and the distance from osteotomy plane to adjacent joint was 16.0 (13.0, 22.0) cm and 4.5 (3.5, 6.0) cm, respectively. 59 metaphysis-fixing components were installed in 43 patients. Type I components were used in single and dual ends of endoprosthesis in 12 and 6 cases respectively. Type II components were used in single and dual ends in 15 and 5 cases respectively. Hybrid endoprosthesis with Type I and II components were used in 5 cases. The mean follow-up time was 26.0 (17, 37) months (range, 12-54 months). The mean MSTS 93 score was 29.0 (28.0, 30.0) points (range, 21-30 points). Implant failures were found in 5 patients, including 2 cases of aseptic loosening (loosening was observed in the cementing diaphysis-fixing stems while no evidence of loosening in metaphysis-fixing components) and 3 cases of local tumor progression. The 2-year implant survival rate was 90.3% (95% CI: 0.81, 0.99). Conclusion:Using 3D-printed intercalary endoprosthesis for reconstruction after intercalary resection of metaphysis-involved bone tumor shows satisfactory functional outcome and implant survival. Moreover, by assembling endoprosthetic components according to the different osteotomy plane, the semi-modularized endoprosthesis also provids a comprehensive and individualized reconstruction for patients with metaphysis-involved intercalary tumor.

Application progress of arterial isolated perfusion chemotherapy in pelvic tumors / 肿瘤研究与临床

Pelvic arterial isolated perfusion chemotherapy is a kind of regional chemotherapy. It works by two balloons placed in inferior vena cava and abdominal aorta and tourniquets placed in both lower extremities. Thus pelvic blood circulation can be isolated from the systemic circulation. The chemotherapy drugs are perfused into the pelvic region to achieve local exposure to higher drug concentration than the systematic chemotherapy. The pelvic arterial isolated perfusion chemotherapy is expected to be a new complementary therapy for unresectable pelvic tumors. The use of this technology in neoadjuvant therapy can achieve downgrading of unresectable tumors, and some patients achieve long-term survival after surgery. There are almost no relevant domestic reports yet, and this article discusses the principles, clinical efficacy, safety and complications of this technology.

Design and function evaluation of 3D-printed hemi-elbow-arthroplastic total humeral prosthesis / 肿瘤研究与临床

Obiective:To investigate the design, the key points of surgery and the outcome of short-term follow-up of hemi-elbow-arthroplastic bionic total humeral prosthesis by using 3D-print.Methods:The clinical data of 8 patients with humerus malignant tumor who underwent total humerus resection and a 3D-printed auxiliary hemi-elbow-arthroplastic total humeral prosthesis replacement from March 2018 to March 2020 at Peking University People's Hospital were retrospectively analyzed. The operative data, oncological outcome, complication profiles of prosthesis and functional status of all 8 patients were also analyzed. There were 3 males and 5 females with a mean age of 5-37 years. Histological diagnosis included 5 cases of osteosarcoma, 2 cases of Ewing's sarcoma and 1 case of chondrosarcoma.Results:The time for production of the prosthesis was (9.8±2.7) d, the operation time was (209±23) min and intraoperative hemorrhage was (569±173) ml. All the prostheses were implanted successfully and no patients experienced intraoperative complications. While 2 patients had postoperative complications, 1 case of temporary palsy of radial nerve and 1 case of local recurrence. LARS artificial ligament or hernia patch was used to reconstruct joint capsule and tendon-ligament attached around the elbow and shoulder joint. The flexion and extension of the elbow was (118±15)° (100-140°) and (11±9)° (0-25°), and the abduction and anteflexion of the shoulder was (28±12)° (15-50°) and (26±9)° (15-40°), respectively. The postoperative Musculoskeletal Tumor Society (MSTS)-93 scale score was (24.1±1.5) scores. The median follow-up time was 17 months (12-32 months), 7 patients had disease-free survival and 1 patient survived with tumor.Conclusions:The novel 3D-printed total humeral prosthesis with hemi-elbow-arthroplasty has a good perioperative safety, which is effective in restoring the function of elbow joint, solving the problem of stress concentration of ulnar marrow lever of total elbow joint prosthesis and lowering long-term wear rate and loosening rate of prosthesis.

Reconstruction with a bionic knee megaprosthesis after resection of a distal femoral osteosarcoma in children / 中华骨科杂志

Objective:We designed and applied a novel, bionic megaprosthesis for distal femur, which substituted the hinged articulation with an artificial ligament and a constrained tibial insert in order to maintain articular stability and reduce stress and the risks of wearing, loosening and breakage.Methods:We reviewed the cases of distal femoral osteosarcoma in children population who were initially treated in our center during 2019. Twelve cases of bionic distal femoral prosthesis (bionic group) and 21 cases of fixed-hinge distal femoral prosthesis (control group) were included. In the bionic group, there were six female and six male with the mean age as 8.8±2.6 y. One patient had pathological fracture. Staging according to Enneking system included 1 case of stage IIA, 10 cases of stage IIB and 1 case of stage III. In the control group, there were seven female and fourteen male with the mean age as 8.6±2.2 y. Pathological fracture was seen in three cases. Staging included 15 cases of stage IIB and 6 cases of stage III.We investigated the peri-operative safety, oncological outcome, complication profiles and post-operative functional status of the bionic prosthesis by comparing the baseline data, operative data, and oncological and prosthetic outcomes between the two groups.Results:The two groups were comparable in terms of baseline data including gender, age, height, weight and onset duration, and operative data including duration of operation (126.7±27.9 min vs 143.3±38.9 min, P=0.203), intra-operative hemorrhage (162.5±212.3 ml vs 247.6±175.6 ml, P=0.224) and duration of wound drainage (6.3±2.4 d vs 6.4±3.4 d, P=0.908). The mean follow-up duration of bionic group was 16.0±4.7 months, during which time three patients had systemic progression and one of them died of disease. Another patient had local recurrence and subluxation of the prosthesis that was treated by amputation. Subluxation might be related to the huge tumor mass and excessive resection of the quadriceps femoris. As for the control group, the mean follow-up duration was 12.7±4.5 months. Three patients had systemic progression and all patients were still alive by last follow-up. Local recurrence was seen in two patients and was treated by excision. No prosthetic complications were seen in the control group. The averaged range of motion (ROM) was greater in the bionic group than that in the control group (120.6°±13.6° vs 92.0°±7.7°, P<0.05), but the MSTS 93 scores were similar between groups (29.1±0.9 vs 29.5±0.6, P=0.337). Conclusion:Compared with the fixed-hinge distal femoral prosthesis, the bionic prosthesis had good peri-operative safety, did not increase the risks of prosthetic complications, and could achieve a better range of motion and a similar functional status based on the results of short-term follow-up.

Abdominal aortic balloon occlusion in the pelvic and sacral tumor resection: An updated review / 中华骨科杂志

Surgical treatment for bone and soft tumors of pelvis and sacrum presents a big challenge, because of the complex anatomy of sacropelvic region, large tumor volume at presentation, rich blood supply to the tumor and visceral involvemen, et al. Therefore, surgical excision and reconstruction are technically difficult for sacropelvic tumors. Extensive intraoperative haemorrhage could be life-threatening, and this issue remains a major concern. How to effectively control bleeding during surgery is critical for successful operation and patient's favorable prognosis. Some previous attempts, such as interventional selective internal iliac artery embolization or manual ligation through an additional anterior approach, were tested to be ineffective. Inspired by the success of resuscitative endovascular balloon occlusion of the aorta (REBOA) which resemble an endovascular tourniquet for traumatic hemorrhagic shock, some researchers have applied this techinique to control surgical bleeding during pelvic or sacral tumor resection.The authors have performed REBOA for more than 1 500 sacropelvic tumr surgeries since 2003 in Peking University People's Hospital. The patient age, the diameter of femoral artery and aorta, atherosclerosis, as well as tumor location, volume and expansion and blood suppy, have to be thoroughly evaluated prior to REBOA administration. Admittedly, the application of REBOA do reduce intraoperative bleeding, shorten the operation duration, improve the safety of surgery, yet some complications were observed including local hematoma at the puncture site, acute arterial thrombosis, femoral artery pseudoaneurysm or occlusio, et al. The purpose of this study is to review the literature on REBOA administration in pelvic and sacral tumors excision, with the focus on its indications, performing procedure, the safety and efficacy, and complications. Moreover, in order to popularize the clinical application of aortic balloon occlusion in the future, we summarize our experience of abdominal aortic balloon occlusion over 10 years.

Sexual knowledge, attitude and associated factors among primary and middle school students / 中国学校卫生

Objective@#To understand the awareness of sexual knowledge among primary and secondary school students, as well as their attitudes towards school sex education and to provide a reference for school-based sex education.@*Methods@#A total of 5 531 primary and secondary school students were selected from Beijing, Chongqing, Heilongjiang (Harbin and Jiamusi) and Hubei (Wuhan and Xiaogan) by stratified cluster sampling and were investigated with self-reported questionnaire.@*Results@#Sex-related knowledge scored 62.33±19.35, with a pass rate of 61.9%, and the excellent rate 17.5%. Sexual knowledge of junior high school students scored 64.30±19.07, with the pass rate of 64.7%, and the excellent rate 22.0%. A large proportion of primary students reported unaware of pubertal growth and HIV/AIDS-related knowledge, and a large proportion of junior high students unaware of reproductive physiology. Multivariate Logistic regression analysis showed region, grade, gender, and suburban areas were related to the level of sexual knowledge(P<0.05). More than 76.0% primary students and 85.9% middle school students agreed on the importance of school sexuality education. 59.7% of primary school students and 73.3% of junior high school students hoped to include school sexuality education in compulsory education courses; 59.8% of primary school students and 68.3% of junior high school students felt that school sexuality education should be equipped with specialized teachers.@*Conclusion@#Chinese primary and secondary school students are lack of sexual knowledge. As students have strong wills to get more information on sexual knowledge, schools should provide them with more comprehensive and effective sex education through appropriate courses and activities.

Efficacy and safety of denosumab combined with surgery in treatment of giant cell tumor of pelvis / 肿瘤研究与临床

Objective To evaluate the safety and efficacy of denosumab in treatment of patients with pelvic giant cell tumor of bone (GCTB) during perioperative period. Methods This is a retrospective observational study. Twenty-three patients diagnosed with pelvic GCTB undergoing perioperative denosumab treatment in Musculoskeletal Tumor Center of Peking University People's Hospital from January 2014 to December 2016 were reviewed. The subjective adverse reactions and mandibular X-ray films were used to assess the drug safety. As for efficacy, imaging findings (including X-ray, CT, magnetic resonance imaging) were reviewed. MSTS-93 scoring system was applied in the postoperative functional assessment. Histological response rate, objective response rate, clinical benefit rate and event-free survival rate were all used to deficit the efficacy of denosumab in the treatment of pelvic GCTB combined with surgery. All the results of postoperative were compared statistically with pelvic GCTB patients who underwent surgery in the same hospital from 1999 to 2009. Results All the patients were firstly diagnosed as classic GCTB except for one case which was malignant pelvic GCTB. All patients received denosumab preoperatively and/or postoperatively, and the average number of medications was 8.43. According to the surgical patterns, patients were divided into intralesional surgery group (13 cases) and wide resection group (10 cases). The follow-up was 5-47 months(mean:27.30 months),recurrence was observed in 2 cases in the intralesional surgery group, none in the wide resection group. After drug administration, 13 cases were partial response, 7 cases were stable disease, the objective response rate was 65.0 % (13/20), and the histologically clearance rate of giant cells was 85.0 % (17/20). No case of osteonecrosis of the jaw was observed in this study, and all laboratory indicators were normal. The average postoperative MSTS-93 score was 26.87. Compared with pelvic GCTB patients who underwent surgical treatment from 1999 to 2009, in the intralesional surgery group, there was no significant difference in the recurrence rate [15.4 % (2/13) vs. 30.8 % (4/13), P = 0.514], but the limb function was significantly increased (P= 0.002). Conclusions Denosumab combined with surgery plays an important role in the multidisciplinary treatment of pelvic GCTB. The neoadjuvant strategy can reduce patient's intraoperative blood loss by shrinking the tumor size which makes the intralesional curettage surgery possible, and also diminishing the recurrence rate. But more attention should be paid to secondary malignant GCTB during the use of denousmab.

Evaluation the quality of life in patients with bone metastases:evidence-based update / 中华骨科杂志

There is increasing recognition of the importance of the quality of life (QOL) since it became an endpoint of clinical practices, a variety of disease-specific quality of life instruments have been developed and used as a means of assessing clinical interventions. Traditional evaluation was performed by researchers who generally ignore the subjective feeling from pa-tiens. At present, many evaluation criteria has paid more attention to the patient's subjective feelings into the scoring system, the assessment tool of patient-reported outcome (PRO) is usually the patient self-rating scale or questionnaire. As a common complica-tions of terminal stages of cancer, the treatment of bone metastases is usually conservative, improving or maintaining the quality of life of patients has been the consensus. Bone metastases trials have employed QLQ-C30 which raised by Europe Organization for Research and Treatment of Cancer (EORTC) or other generic health related QOL measurement, such as functional assessment of cancer therapy-general (FACT-G) and the MOS 36-item short from health survey (SF-36). But they lack specificity and accuracy in the assessment. EORTC QLQ-BM22 scale is considered as a bone metastases specific scale which was introducted in 2009, after the reliability, validity, cross-cultural adaptability verification, with the combination of EORTC QLQ-C 30 or used alone, has in-creasingly applied to clinical trials and practice for QOL assessment of bone metastatic cancer patients in recent years. It complete the EORTC evaluation system, which has significant value for assessing efficacy. EORTC QLQ-BM 22 has been translated into sim-plified Chinese and evaluated its utility, could be used in China as an effective questionnaire in evaluating the QOL for patients with bone metastases. In this study, current situation and progress of QOL measuring tools for bone metastases patients is re-viewed, in order to help researchers choose appropriate scale and better assess the efficacy, find the pros and cons to guide the clinical treatment decision.

Evaluation the quality of life in patients with bone metastases:evidence-based update / 中华骨科杂志

There is increasing recognition of the importance of the quality of life (QOL) since it became an endpoint of clinical practices, a variety of disease-specific quality of life instruments have been developed and used as a means of assessing clinical interventions. Traditional evaluation was performed by researchers who generally ignore the subjective feeling from pa-tiens. At present, many evaluation criteria has paid more attention to the patient's subjective feelings into the scoring system, the assessment tool of patient-reported outcome (PRO) is usually the patient self-rating scale or questionnaire. As a common complica-tions of terminal stages of cancer, the treatment of bone metastases is usually conservative, improving or maintaining the quality of life of patients has been the consensus. Bone metastases trials have employed QLQ-C30 which raised by Europe Organization for Research and Treatment of Cancer (EORTC) or other generic health related QOL measurement, such as functional assessment of cancer therapy-general (FACT-G) and the MOS 36-item short from health survey (SF-36). But they lack specificity and accuracy in the assessment. EORTC QLQ-BM22 scale is considered as a bone metastases specific scale which was introducted in 2009, after the reliability, validity, cross-cultural adaptability verification, with the combination of EORTC QLQ-C 30 or used alone, has in-creasingly applied to clinical trials and practice for QOL assessment of bone metastatic cancer patients in recent years. It complete the EORTC evaluation system, which has significant value for assessing efficacy. EORTC QLQ-BM 22 has been translated into sim-plified Chinese and evaluated its utility, could be used in China as an effective questionnaire in evaluating the QOL for patients with bone metastases. In this study, current situation and progress of QOL measuring tools for bone metastases patients is re-viewed, in order to help researchers choose appropriate scale and better assess the efficacy, find the pros and cons to guide the clinical treatment decision.

Effect of denosumab combined with surgery on sacral giant cell tumor / 肿瘤研究与临床

Objective To evaluate the clinical benefits of denosumab in treatment of sacral giant cell tumor of bone(GCTB) when used preoperatively or postoperatively along with surgery, and to analysis the improvement of sacral nerve function. Methods Thirty patients diagnosed as sacral GCTB in Musculoskeletal Tumor Center of Peking University People's Hospital from April 2014 to July 2016 were divided into control group (10 cases), post-operative group (9 cases), and neoadjuvant group (11 cases). Patients in the post-operative and neoadjuvant group were treated with 120 mg of subcutaneous denosumab every 4 weeks with loading doses on days 8 and 15 of the first cycle. Results Three patients in the control cohort 1 had recurrence (3/10), no recurrence occurred in the post-operative group (0/9), and 3 patients in the neoadjuvant group had recurrence(3/11).There were no significant differences in event-free survival(EFS) among the three groups (P = 0.133). The objective response rate (OTR) was 63.6 % (7/11) in the neoadjuvant group based on the RECIST 1.1 criteria for evaluating the efficacy of solid tumors. Five cases had significant pain improvement (defined 2 points improved) and had much better bladder and bowel functions. Four patients were able to have their indwelling catheters removed after neoadjuvant denosumab treatment. Conclusions Neoadjuvant therapy with denosumab can relieve the symptoms and neurologic deficits caused by nerve compression and can diminish the intraoperative blood loss. Surgical removal of the tumor is still the basic treatment of sacral GCTB.

Plate-cable system for acromioclavicular joint dislocation based on the principle of anchor / 局解手术学杂志

Objective To investigate the biomechanical characteristics of the acromioclavicular joint,put forward the treatment of acromioclavicular joint dislocation based on the principle of anchor and apply to clinic.Methods From August 2011 to March 2015,24 patients with the acromioclavicular joint dislocation in department of orthopedics of Chinese Medicine Hospital of Changshu were divided into the treatment group and the control group,with 12 cases in each group.The treatment group were treated by vertical suspension buttons steel cable system based on principle of anchor,while the control group were treated by the hook plate technology.The clinical results of the two groups were evaluated by Karlsson score system.Results All the patients were followed up for 6 to 12 months.In terms of the curative effect in the treatment group,there were 11 cases of excellent and 1 case of good,with the excellent and good rate of 100%,and no complication occured.In the control group,there were 7 cases of excellent and 3 case of good,with the excellent and good rate of 83.3%.And there was 1 case of subacromial osteolysis.Conclusion To treat acromioclavicular joint dislocation above Rockwood Ⅲ with vertical suspension buttons steel cable system based on principle of anchor may be an ideal treatment method.