Journal of Orthopaedic Surgery 2012;20(1):98-102
Pedicle freezing with liquid nitrogen for
malignant bone tumour in the radius: a new
technique of osteotomy of the ulna
Tomoaki Torigoe,1 Yoshimasa Tomita,1 Yoshiyuki Iwase,1 Kentaro Aritomi,1 Yoshiyuki Suehara,1 Taketo Oukubo,1
Akira Sakurai,1 Atsuhiko Terakado,1 Tatsuya Tatsuya,1 Kazuo Kaneko,1 Tsuyoshi Saito,2 Yasuo Yazawa3
Department of Orthopaedic Surgery, Juntendo University School of Medicine, Tokyo, Japan
Department of Surgical Pathology, Juntendo University School of Medicine, Tokyo, Japan
3
Department of Orthopaedic Oncology, Saitama International Medical Center, Saitama, Japan
1
2
INTRODUCTION
ABSTRACT
We describe a new technique of pedicle freezing of
the distal radius with malignant bone tumour and
osteotomy of the normal ulna. The distal radius
was sufficiently elevated to enable freezing without
damaging adjacent tissues by releasing the distal
radio-ulnar and radio-carpal joint and cutting the
middle third of the ulna. The distal radius (including
the tumour) was soaked in liquid nitrogen and the
defect filled with iliac grafts. The ulna was repaired
with plate and screws and was united at month 2.
There was no local recurrence and the postoperative
function score was 93%. This technique decreases
the risk of non-union of the osteotomy site of the
tumorous bone.
Key words: bone neoplasms; forearm; freezing
In Japan, liquid nitrogen–processed autologous bone
grafts are often used for reconstruction following
wide resection of malignant bone tumours.1 In this
cryosurgery, bones frozen (-196ºC) by liquid nitrogen
become dead, but viable cells can be found in the
frozen bone after months.2 Extracorporeal freezing
with liquid nitrogen following en bloc resection is
a basic method (Fig. 1a), but it necessitates 2-side
osteotomies and there is a risk of non-union, because
the return of the osteoblasts and other viable cells
in frozen bone may be delayed. Pedicle freezing
necessitates no or one-side osteotomy only, and
liquid nitrogen–treated bone maintains continuity
with remaining bone without freezing (Fig. 1b). This
reduces the risk of non-union and enables immediate
return of viable cells. Nonetheless, this technique is
difficult to perform on distal forearm bones (radius
and ulna), as they are strongly connected by the
interosseous membrane. We report a new surgical
Address correspondence and reprint requests to: Dr Tomoaki Torigoe, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan. E-mail:
[email protected]
Vol. 20 No. 1, April 2012
Pedicle freezing with liquid nitrogen for malignant bone tumour in the radius
(a)
99
(b)
Figure 1 (a) Extracorporeal freezing of the tumour located in the diaphysis of the femur with 2-site osteotomy, followed by
osteosynthesis with an intramedullary nail. (b) Pedicle freezing of the tumour located in the diaphysis of the femur with one-site
osteotomy, followed by osteosynthesis with an intramedullary nail.
(a)
(b)
Figure 3 (a) Round-shaped tumour cells and multi-nuclear
giant cells of benign giant cell tumour (GCT) of the bone. (b)
Pleomorphic and large tumour cells with atypical nucleolus
and mitoses of malignant GCT of the bone.
Figure 2 Radiographs showing an osteolytic lesion from
the epiphysis to the metaphysis of the distal radius, with no
marginal sclerosis and extraskeletal lesion.
technique, in which a normal ulna osteotomy was
performed and the tumour was treated with pedicle
freezing without radius osteotomy.
CASE REPORT
In March 2009, a 20-year-old woman presented with
right wrist pain and tenderness but no swelling or
localised pain. She had a one-year history of wrist
pain without any antecedent traumatic episode.
Radiographs revealed an osteolytic lesion in the
epiphysis to metaphysis of the distal radius, and the
marginal sclerosis of the bone was unclear (Fig. 2). No
extraskeletal lesions were noted. A biopsy confirmed
the pathological diagnosis to be benign giant cell
tumour (GCT) of bone (Fig. 3a).
One month later, the patient underwent
curettage (with a high-speed burr) and cryotherapy
and bone grafting with artificial bone (β-TCP).
At postoperative month 6, the patient had local
recurrence in the distal radius and underwent
curettage
again.
Histopathology
revealed
proliferation of atypical tumour cells (Fig. 3b). The
new diagnosis was secondary malignant GCT of
the bone (T2N0M0, stage IIB, International Union
Against Cancer classification) [Fig. 4]. Chemotherapy
was administered immediately, with 2 courses of
Journal of Orthopaedic Surgery
100 T Torigoe et al.
high-dose ifosfamide and 2 courses of cisplatin and
doxorubicin. Radiotherapy was not performed.
The patient underwent liquid nitrogen processing
of the affected bone. An almost 15-cm spindle-shaped
skin incision was made from the dorsal side of the
wrist to the forearm (including the surgical scar
from the previous surgery). The third and the fourth
extensor compartments and the extensor pollicis
longus, extensor digitorum communis, and extensor
indicis proprius tendons were sacrificed, because the
previous surgery passed through these compartments,
which were considered contaminated with malignant
tumour cells. All extensor tendons in the first,
Figure 4 Local recurrence of the osteolytic lesion in
the epiphysis of the distal radius showing high intensity in
magnetic resonance imaging using fat suppression and
gadolinium.
(a)
(b)
second, fifth, and sixth extensor compartments were
salvaged. The distal radius was slightly elevated to
the dorsal side, and the ligaments and joint capsule
around the distal radio-ulnar joint and radio-carpal
joint were resected. The volar side of the distal radius
could be observed from the dorsal side. The flexor
tendons were separated from the distal radius and
preserved, and the pronator quadratus muscle was
sacrificed with the distal radius. The muscles on
the radius along the distal third of the forearm and
the interosseous membrane were resected, and the
periosteum of the radius was retained as a tumour
barrier. Although one third of the radius was freed
from any soft-tissue structures, the distal radius
could not be sufficiently elevated for liquid nitrogen
soaking, because the forearm interosseous membrane
remained attached to the middle to proximal portion
of the bone (Fig. 5).
Instead of en bloc resection of the distal radius,
we osteotomised the middle third of the ulna, with
a 3 cm safety margin to prevent normal soft tissues
from freezing. This enabled the forearm to be bent
almost 180º, and the remaining protruded radius was
treated with liquid nitrogen (Fig. 5). The distal radius,
including the tumour and its margin, was isolated
from other surgical areas with drapes; curettage was
performed to prevent fracture of the radius because
tumour was expected to expand when frozen. The
distal radius was frozen in liquid nitrogen for 20
minutes followed by defrosting at room temperature
for 15 minutes and in distilled water for 10 minutes
(Fig. 5). The bone defect was filled with autologous
bone grafts from the ilium. The elevated radius was
returned to the original position and the lunateradial, radio-ulnar ligaments, and joint capsule were
(c)
Figure 5 (a) The distal radius cannot be sufficiently elevated to expose the lesion to liquid nitrogen after release of the wrist
joint and distal radio-ulnal joint, because the interosseous membrane remains in the middle to proximal region of the forearm.
(b) The forearm can be bent almost 180º after osteotomy of the ulna. The distal radius protrudes from the soft tissue of the
forearm. (c) The distal radius is soaked with liquid nitrogen.
Vol. 20 No. 1, April 2012
Pedicle freezing with liquid nitrogen for malignant bone tumour in the radius 101
repaired. The ulna was fixed with a plate and screws.
The extensor pollicis longus tendon was repaired
with a tendon transfer from the extensor pollicis
brevis, whereas the extensor digitorum communis
and extensor indicis proprius were repaired with
a tendon transfer from the extensor carpi radialis
brevis. The skin defect from the spindle-shaped skin
incision was reconstructed with a local flap and a
free skin graft. Although the distal radio-ulnar joint
and radio-carpal joint were stabilised, the arm was
immobilised with a short-arm splint for 4 weeks in
order to protect the transferred tendons.
The patient then underwent 4 further cycles of
chemotherapy. The osteotomy site in the ulna was
united at month 2 (Fig. 6). The patient remained
continuously disease-free and had a functional score
(the Enneking system) of 93% (pain 5, function 5,
emotional acceptance 3, hand positioning 5, dexterity
5, lifting ability 5) at year one (Fig. 7). There was no
articular cartilage collapse in the distal radius.
DISCUSSION
Figure 6 Osteosynthesis and bone union of the osteotomy
site at the middle third of the ulna.
Liquid nitrogen treatment for malignant bone
tumours1,3 has been approved as advanced medical
Figure 7 At month 6, the range of motion of the right wrist joint was complete except for palmar flexion.
102 T Torigoe et al.
technology by the Ministry of Health, Labor and
Welfare of Japan. Reconstruction using liquid
nitrogen–processed autologous bone grafts enables
osteoinduction, preservation of the cartilage matrix,
perfect anatomical fits, easy attachment of tendons
and ligaments, low cost, and low risk of infection.4,5
The conventional technique for liquid nitrogen
treatment involves en bloc resection of the bone
and extracorporeal soaking in liquid nitrogen. The
treated bone was then returned to its original site for
reconstruction. This technique is associated with a
relatively high risk of non-union, because it involves
a 2-side osteotomy and the bones treated with liquid
nitrogen have no viable cells for months. Initially,
frozen bone appears to contain no live cells but viable
cells become evident again after several months.2 Four
of 36 cases treated with liquid nitrogen resulted in
non-union; 3 of which were treated extracorporeally.6
The pedicle freezing technique requires osteotomy of
the proximal side only. The treated bone maintains
in continuity with the normal bone.7 This technique
Journal of Orthopaedic Surgery
is practical in the thigh and the upper arm (as each
contains a single bone). The femur or humerus can
be easily elevated for liquid nitrogen soaking after
resection of the surrounding soft tissue. Pedicle
freezing for bone tumours in the distal shafts of the
radius and ulna is difficult, as elevation of either bone
in the forearm is not sufficient for liquid nitrogen
treatment, owing to the intra-osseous membrane
connecting the radius and ulna. Conventional
treatment entails total resection of the distal radius
and reconstruction with a vascularised fibular graft.
Our technique involves osteotomy of normal bone.
This eliminates the risk of non-union at the osteotomy
site after liquid nitrogen treatment of the tumorous
bone. This technique enables restoration of wrist
joint function owing to the perfect anatomic fit of the
wrist. There is no invasion of the donor site of fibular
grafts. It can be easily applied for pasteurisation and
intra-operative radiotherapy. The level of osteotomy
should be same as the exposure level of the tumorous
bone.
REFERENCES
1. Marcove RC, Abou Zahr K, Huvos AG, Ogihara W. Cryosurgery in osteogenic sarcoma: report of three cases. Compr Ther
1984;10:52–60.
2. Tanzawa Y, Tsuchiya H, Shirai T, Hayashi K, Yo Z, Tomita K. Histological examination of frozen autograft treated by liquid
nitrogen removed after implantation. J Orthop Sci 2009;14:761–8.
3. Tsuchiya H, Wan SL, Sakayama K, Yamamoto N, Nishida H, Tomita K. Reconstruction using an autograft containing tumour
treated by liquid nitrogen. J Bone Joint Surg Br 2005;87:218–25.
4. Nishida H, Tsuchiya H, Tomita K. Re-implantation of tumour tissue treated by cryotreatment with liquid nitrogen induces
anti-tumour activity against murine osteosarcoma. J Bone Joint Surg Br 2008;90:1249–55.
5. Yamamoto N, Tsuchiya H, Tomita K. Effects of liquid nitrogen treatment on the proliferation of osteosarcoma and the
biomechanical properties of normal bone. J Orthop Sci 2003;8:374–80.
6. Tanizawa Y, Tsuchiya H, Yamamoto N, Takeuchi A, Tomita K. Pedicle frozen autograft reconstruction in malignant bone
tumors. Central Japan J Orthop Surg Trauma 2007;50:703–4.
7. Tsuchiya H, Nishida H, Srisawat P, Shirai T, Hayashi K, Takeuchi A, et al. Pedicle frozen autograft reconstruction in malignant
bone tumors. J Orthop Sci 2010;15:340–9.