Complications and functional evaluation of 17 saddle prostheses for resection of periacetabular tumors

Does adding sacroiliac (type IV) resection to periacetabular (type II) resection increase complications or provide worse clinical outcomes? An institutional experience and systematic review

BACKGROUND AND OBJECTIVES

Internal hemipelvectomy is a limb sparing procedure most commonly indicated for malignant bone and soft tissue tumors of the pelvis. Partial resection and pelvic reconstruction may be challenging for orthopedic oncologists due to late presentation, high tumor burden, and complex anatomy. Specifically, wide resection of tumors involving the periacetabular and sacroiliac (SI) regions may compromise adjacent vital neurovascular structures, impair wound healing, or limit functional recovery. We aimed to present a series of patients treated at our institution who underwent periacetabular internal hemipelvectomy (Type II) with or without sacral extension (Type IV) in combination with a systematic review to investigate postoperative complications, functional outcomes, and implant and patient survival following pelvic tumor resection via Type II hemipelvectomy with or without Type IV resection.

MATERIALS AND METHODS

A surgical registry of consecutive patients treated with internal hemipelvectomy for primary or secondary pelvic bone tumors at our institution since 1994 was retrospectively reviewed. All type II resection patients were stratified into two separate cohorts, based on whether or not periacetabular resection was extended beyond the SI joint to include the sacrum (Type IV), as per the Enneking and Dunham classification. Patient demographics, operative parameters, complications, and oncological outcomes were collected. Categorical and continuous variables were compared with Pearson's chi square or Fisher's exact test and the Mann-Whitney U test, respectively. Literature review according to PRISMA guidelines queried studies pertaining to patient outcomes following periacetabular internal hemipelvectomy. The search strategy included combinations of the key words "internal hemipelvectomy", "pelvic reconstruction", "pelvic tumor", and "limb salvage". Pooled data was compared using Pearson's chi square. Statistical significance was established as p < 0.05.

RESULTS

A total of 76 patients were treated at our institution with internal hemipelvectomy for pelvic tumor resection, of whom 21 had periacetabular resection. Fifteen patients underwent Type II resection without Type IV involvement, whereas six patients had combined Type II/IV resection. There were no significant differences between groups in operative time, blood loss, complications, local recurrence, postoperative metastasis, or disease mortality. Systematic review yielded 69 studies comprising 929 patients who underwent internal hemipelvectomy with acetabular resection. Of these, 906 (97.5 %) had only Type II resection while 23 (2.5 %) had concomitant Type II/IV resection. While overall complication rates were comparable, Type II resection alone produced significantly fewer neurological complications when compared to Type II resection with sacral extension (3.9 % vs. 17.4 %, p = 0.001). No significant differences were found between rates of wound complications, infections, or construct failures. Local recurrence, postoperative metastasis, and survival outcomes were similar. Type II internal hemipelvectomy without Type IV resection on average produced higher postoperative MSTS functional scores than with Type IV resection.

CONCLUSION

In our series, the two groups exhibited no differences. From the systematic review, operative parameters, local recurrence or systemic metastasis, implant survival, and disease mortality were comparable in patients undergoing Type II internal hemipelvectomy alone compared to patients undergoing some combination of Type II/IV resection. However, compound resections increased the risk of neurological complications and experienced poorer MSTS functional scores.

LUMiC Endoprosthetic Reconstruction of Periacetabular Tumor Defects: A Multicenter Follow-up Study

UPDATE

This article was updated on July 17, 2024 because of a previous error, which was discovered after the preliminary version of the article was posted online. The byline that had read "Richard E. Evenhuis, MD 1 , Michiel A.J. van de Sande, MD, PhD 1,2 , Marta Fiocco, PhD 2,3,4 , Demien Broekhuis, MD 1 , Michaël P.A. Bus, MD, PhD 1 , and the LUMiC® Study Group*" now reads "Richard E. Evenhuis, MD 1 , Michiel A.J. van de Sande, MD, PhD 1,2 , Marta Fiocco, PhD 2,3,4 , Edwin F. Dierselhuis, MD, PhD 5 , Demien Broekhuis, MD 1 , Michaël P.A. Bus, MD, PhD 1 , and the LUMiC® Study Group*". The Department of Orthopaedic Surgery, Radboudumc, Nijmegen, The Netherlands, has been added as the affiliation for Edwin F. Dierselhuis, MD, PhD.

BACKGROUND

We previously reported promising early results for periacetabular tumor reconstructions using the LUMiC prosthesis. The current study evaluates mid-term complications, revision rates, cumulative incidence of implant revision, and risk factors for complications in a multicenter cohort.

METHODS

We assessed patients in whom a tumor defect after type P1b+2, P2, P2+3, or P1b+2+3 internal hemipelvectomy was reconstructed with a LUMiC prosthesis during the period of 2008 to 2022. Complications were reported according to the Henderson classification. Competing risks models were used to estimate the cumulative incidence of implant revision for mechanical and nonmechanical reasons, and reoperations for any complication. Cox models were used to study the effect of risk factors on dislocation and infection.

RESULTS

One hundred and sixty-six patients (median follow-up, 4.2 years [interquartile range, 2.6 to 7.6 years]) were included. A total of 114 (69%) were treated for a primary malignant tumor, 46 (28%) for metastatic carcinoma, 5 (3%) for a benign aggressive lesion, and 1 (1%) for another reason. One hundred and sixty-five reoperations were performed in 82 (49%) of the patients; 104 (63%) of the reoperations were within 6 months. Thirty-two (19%) of 166 implants were revised: 13 (8%) for mechanical reasons, mainly dislocation (n = 5, 3%), and 19 (11%) for nonmechanical reasons, mainly periprosthetic joint infection (PJI) (n = 15, 9%). The cumulative incidences of revision for mechanical reasons and PJI (Henderson 1 to 4) at 2, 5, and 10 years were 11% (95% confidence interval [CI], 7% to 17%), 18% (12% to 25%), and 24% (16% to 33%), respectively. Previous surgery at the same site was associated with an increased dislocation risk (cause-specific hazard ratio [HR CS ], 3.0 [95% CI, 1.5 to 6.4]; p < 0.01), and resections involving the P3 region were associated with an increased infection risk (HR CS , 2.5 [95% CI, 1.4 to 4.7]; p < 0.01).

CONCLUSIONS

Despite a substantial reoperation risk, the LUMiC prosthesis demonstrated its durability in the mid-term, with a low mechanical revision rate and most patients retaining their primary implant. Most complications occur in the first postoperative months. Patients with previous surgery at the same site had an increased dislocation risk and might benefit from more conservative rehabilitation and aftercare. Measures should be aimed at reducing the PJI risk, especially in resections involving the P3 region.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Precise single column resection and reconstruction with femoral head plus total hip replacement for primary malignant peri-acetabulum tumors

To evaluate whether single acetabular column can be reserved and the effect of reconstruction with femoral head plus total hip replacement (THR) for primary malignant peri-acetabulum tumors. From 2007 to 2015, nineteen patients with primary malignant peri-acetabulum tumors were enrolled. All cases underwent single column resection with clear surgical margins. Ten of the 19 tumor's resections were assisted by computer navigation. Femoral heads were applied to reconstruct anterior or posterior column defects; THR was used for joint reconstruction. The surgical safety, oncologic outcome and prosthesis survivorship and function were evaluated by regular follow-up. The average follow-up period was 65.9 months. Surgical margins contained wide resection in 12 cases and marginal resection in 7 cases. One patient with Ewing's sarcoma died 14 months postoperative due to lung metastasis. One case with chondrosarcoma had recurrence. One prosthesis was removed due to infection. The average MusculoSkeletal Tumor Society (MSTS) function score was 83.7%. Due to the relative small number of cases, there was no significant difference in the recurrence rate and prosthesis failure rate between the navigation group and non-navigation group. Single column resection and reconstruction with femoral head autograft plus THR is an effective, safe method with less complication rate and better functional outcome for patients with peri-acetabular tumors.

Custom three-dimensional printed implants for reconstruction of oncologic pelvic defects

The use of three-dimensional printed implants in the field of orthopedic surgery has become increasingly popular and has potentiated hip reconstruction in the setting of oncologic resections of the pelvis and acetabulum. In this review, we examine and discuss the indications and technical considerations for custom implant reconstruction of pelvic defects.

What are the 2-year survivorship outcomes of custom hemipelvis reconstruction after hemipelvectomy and revision arthroplasty? The evolution of a custom ilium "monoflange"

BACKGROUND

Innovations in machined and three-dimensionally (3D) printed implant technology have allowed for customized complex pelvic reconstructions. We sought to determine the survivorship of custom hemipelvis reconstruction using ilium-only fixation at a minimum 2-year follow-up, their modes of failure, and the postoperative complications resulting from the procedure.

METHODS

A retrospective review identified 12 consecutive patients treated with custom hemipelvis reconstruction. Indications for surgery were bone tumor requiring internal hemipelvectomy (four patients) or multiply revised, failed hip arthroplasty with massive bone loss (eight patients). All patients had a minimum of 2-year follow-up with a mean of 60.5 months. Kaplan-Meier survivorship analysis was determined for all patients. Postoperative complications and reoperations were categorized for all patients.

RESULTS

At a mean of 60.5 months, 11 of 12 patients had retained their custom implant (92% survivorship). One implant was removed as a result of an acute periprosthetic joint infection (PJI). There were no cases of aseptic loosening. Seven of 12 patients required reoperation (three PJI; two dislocations; two superficial wound complications), with five patients going on to reoperation-free survival.

CONCLUSIONS

Custom hemipelvis reconstruction utilizing an ilium monoflange provides durable short-term fixation at a minimum 2-year follow-up. Reoperation for infection and dislocation is common.

Less is better than more with resection of periacetabular tumors - A retrospective 16 years study and literature review

Introduction

Wide resections of periacetabular tumors create a sizeable bony defect that inevitably results in severe loss of function. Reconstruction of such defects usually requires using large metal implants, a feature associated with considerable surgery extension and complications. The aim of this study is to report resection with no reconstruction of the bony defect. In this retrospective study, we reviewed a consecutive series of 16 patients diagnosed with malignant periacetabular tumors and underwent en-bloc resection without reconstructing their remaining bone defect.

Methods

Records were reviewed of 16 consecutive patients diagnosed with malignant periacetabular tumors and underwent en-bloc resection without reconstructing their remaining bony defect. Measurements included: the duration of surgery, blood loss, hemoglobin levels and the need for blood transfusions, data on other hospitalization characteristics, and intraoperative and postoperative complications.

Results

Sixteen patients with malignant periacetabular bone tumors and extensive bone destruction underwent wide periacetabular tumor resection with a mean follow-up of 75 months and a mean age of 53 years. The average HOOS score was 46 (range: 20 to 76), and the mean MSTS score was 13% (range: 0 to 15). The mean operative time was 4.1 h, and the mean blood loss was 1200 ml. At their most recent follow-up, patients had a mean shortening of their operated extremity of 4.8 cm, and all could ambulate with assisting devices.

Conclusion

Wide resection of periacetabular tumors without reconstruction provides acceptable levels of function and was associated with shorter surgical time, less blood loss and fewer postoperative complications compared to resection with reconstruction. Therefore, this approach may be considered a viable surgical option in patients with an extensive malignant periacetabular.

Level III

Retrospective study.

Surgical Site Infection after Bone Tumor Surgery: Risk Factors and New Preventive Techniques

The management of malignant bone tumors requires multidisciplinary interventions including chemotherapy, radiation therapy, and surgical tumor resection and reconstruction. Surgical site infection (SSI) is a serious complication in the treatment of malignant bone tumors. Compared to other orthopedic surgeries, the surgical treatment of malignant bone tumors is associated with higher rates of SSIs. In patients with SSIs, additional surgeries, long-term administrations of antibiotics, extended hospital stays, and the postponement of scheduled adjuvant treatments are required. Therefore, SSI may adversely affect functional and oncological outcomes. To improve surgical outcomes in patients with malignant bone tumors, preoperative risk assessments for SSIs, new preventive techniques against SSIs, and the optimal use of prophylactic antibiotics are often required. Previous reports have demonstrated that age, tumor site (pelvis and tibia), extended operative time, implant use, body mass index, leukocytopenia, and reconstruction procedures are associated with an increased risk for SSIs. Furthermore, prophylactic techniques, such as silver and iodine coatings on implants, have been developed and proven to be efficacious and safe in clinical studies. In this review, predictive factors of SSIs and new prophylactic techniques are discussed.

Clinical application of 3D-printed patient-specific guide plate combined with computer navigation in acetabular reconstruction following resection of periacetabular tumors

Background

The precise acetabular reconstruction has historically been a challenging procedure. 3D-printed patient-specific guide (PSG) and computer navigation (CN) technologies have been used to assist acetabular component positioning and pelvic reconstruction. This precise reconstruction approach may translate into clinical benefit.

Methods

The clinical data of 84 patients who underwent periacetabular malignant tumor resection and screw-rod-acetabular cage system reconstruction in our center from January 2013 to December 2020 were retrospectively analyzed. Patients were divided into four groups: free hand (FH) group, PSG group, CN group, and PSG combined with computer navigation (PSG + CN) group. The operation time, intraoperative blood loss, and number of fluoroscopy views were recorded. The oncological prognosis, radiographic measurements of the acetabulum, limb function data, and postoperative complications were compared among groups. And finally, we evaluated the risk factors for mechanical failure of the prosthesis.

Results

The postoperative X-ray and computed tomography (CT) scan revealed that the vertical offset discrepancy (VOD) between affected side and contralateral side was 8.4±1.9, 5.9±2.2, 4.1±1.3, and 2.4±1.2 mm in each groups; the horizontal offset discrepancy (HOD) was 9.0±1.9, 6.1±2.2, 3.2±1.3, and 2.1±1.2 mm, correspondingly; the abduction angle discrepancy (ABAD) was 8.6°±1.8°, 5.6°±2.0°, 2.5°±1.3°, and 1.8°±0.9°, respectively; the anteversion angle discrepancy (ANAD) was 5.9°±1.6°, 3.6°±1.7°, 2.9°±1.6°, and 1.9°±0.9°, correspondingly. Statistical results show that the PSG + CN group was superior to the FH group and the PSG group in terms of acetabular position and limb function (P<0.05). Body mass index (P=0.040) and resection type (P=0.042) were found to be the high-risk factors for mechanical failure of the prosthesis.

Conclusions

PSG + CN has potential advantages in improving the accuracy and safety of acetabular positioning and reconstruction.

Periacetabular reconstruction following limb-salvage surgery for pelvic sarcomas

Limb-salvage surgery for pelvic sarcomas remains one of the most challenging surgical procedures for musculoskeletal oncologists. In the past several decades, various surgical techniques have been developed for periacetabular reconstruction following pelvic tumor resection. These methods include endoprosthetic reconstruction, allograft or autograft reconstruction, arthrodesis, and hip transposition. Each of these procedures has its own advantages and disadvantages, and there is no consensus or gold standard for periacetabular reconstruction. Consequently, this review provides an overview of the clinical outcomes for each of these reconstructive options following pelvic tumor resections. Overall, high complication rates are associated with the use of massive implants/grafts, and deep infection is generally the most common cause of reconstruction failure. Functional outcomes decline with the occurrence of severe complications. Further efforts to avoid complications using innovative techniques, such as antibiotic-laden devices, computer navigation, custom cutting jigs, and reduced use of implants/grafts, are crucial to improve outcomes, especially in patients at a high risk of complications.

Impact of Surgical Resection and Reasons for Poor Prognosis of Pelvic Osteosarcoma Based on the Bone Tumor Registry in Japan

Simple Summary

Pelvic osteosarcoma has a poor prognosis compared to osteosarcomas in other locations, and the reasons for this remains unknown. Surgical resection of pelvic osteosarcoma is technically demanding and often results in dysfunction and complications. In this study, we investigated the reasons underlying the poor prognosis of pelvic osteosarcoma by comparing it to femoral osteosarcoma using data from the Bone Tumor Registry in Japan. We used propensity score analysis to determine whether surgical resection of pelvic osteosarcoma improved its prognosis. We demonstrated that pelvic osteosarcoma had a poor prognosis because it occurred more often in the elderly, often had a larger tumor size, and had metastasis at presentation more often in comparison to femoral osteosarcoma. These three factors were also associated with the non-surgical treatment of pelvic osteosarcoma, which also led to a poor outcome. The overall survival rate was only comparable in pelvic osteosarcoma and femoral osteosarcoma in cases treated with surgical resection. Propensity score analysis revealed that surgical treatment improved the prognosis of pelvic osteosarcoma. As such, we propose that surgical resection should be considered based on tumor stage and patient age in order to improve the prognosis of pelvic osteosarcoma.

Abstract

Pelvic osteosarcoma has a poor prognosis compared to osteosarcomas in other locations, and the reasons for this remain unknown. Surgical resection of pelvic osteosarcoma is technically demanding and often results in dysfunction and complications. In this study, we investigated the reasons underlying the poor prognosis of pelvic osteosarcoma by comparing it to femoral osteosarcoma using data from the Bone Tumor Registry in Japan. We used propensity score analysis to determine whether surgical resection of pelvic osteosarcoma improved its prognosis. We demonstrated that pelvic osteosarcoma had a poor prognosis because it occurred more often in the elderly, often had larger tumor size, and had metastasis at presentation more often in comparison to femoral osteosarcoma. These three factors were also associated with the non-surgical treatment of pelvic osteosarcoma, which also led to a poor outcome. The overall survival rate was only comparable in pelvic osteosarcoma and femoral osteosarcoma in cases treated with surgical resection. Propensity score analysis revealed that surgical treatment improved the prognosis of pelvic osteosarcoma. As such, we propose that surgical resection should be considered based on tumor stage and patient age in order to improve the prognosis of pelvic osteosarcoma.

Limb-salvage reconstruction following resection of pelvic bone sarcomas involving the acetabulum

AIMS

Limb salvage for pelvic sarcomas involving the acetabulum is a major surgical challenge. There remains no consensus about what is the optimum type of reconstruction after resection of the tumour. The aim of this study was to evaluate the surgical outcomes in these patients according to the methods of periacetabular reconstruction.

METHODS

The study involved a consecutive series of 122 patients with a periacetabular bone sarcoma who underwent limb-salvage surgery involving a custom-made prosthesis in 65 (53%), an ice-cream cone prosthesis in 21 (17%), an extracorporeal irradiated autograft in 18 (15%), and nonskeletal reconstruction in 18 (15%).

RESULTS

The rates of major complications necessitating further surgery were 62%, 24%, 56%, and 17% for custom-made prostheses, ice-cream cone prostheses, irradiated autografts and nonskeletal reconstructions, respectively (p = 0.001). The ten-year cumulative incidence of failure of the reconstruction was 19%, 9%, 33%, and 0%, respectively. The major cause of failure was deep infection (11%), followed by local recurrence (6%). The mean functional Musculoskeletal Tumour Society (MSTS) scores were 59%, 74%, 64%, and 72%, respectively. The scores were significantly lower in patients with major complications than in those without complications (mean 52% (SD 20%) vs 74% (SD 19%); p < 0.001). For periacetabular resections involving the ilium, the mean score was the highest with custom-made prostheses (82% (SD 10%)) in patients without any major complication; however, nonskeletal reconstruction resulted in the highest mean scores (78% (SD 12%)) in patients who had major complications. For periacetabular resections not involving the ilium, significantly higher mean scores were obtained with ice-cream cone prostheses (79% (SD 17%); p = 0.031).

CONCLUSION

Functional outcome following periacetabular reconstruction is closely associated with the occurrence of complications requiring further surgery. For tumours treated with periacetabular and iliac resection, skeletal reconstruction may result in the best outcomes in the absence of complications, whereas nonskeletal reconstruction is a reasonable option if the risk of complications is high. For tumours requiring periacetabular resection without the ilium, reconstruction using an ice-cream cone prosthesis supported by antibiotic-laden cement is a reliable option. Cite this article: Bone Joint J 2021;103-B(4):795-803.

Complication rate, functional outcomes, and risk factors associated with carbon ion radiotherapy for patients with unresectable pelvic bone sarcoma

BACKGROUND

To the authors' knowledge, carbon ion radiotherapy (CIRT) is one of the few curative treatments for unresectable pelvic bone sarcoma. The current study investigated the complications, functional outcomes, and risk factors of CIRT.

METHODS

Of 112 patients who were treated with CIRT for unresectable pelvic bone sarcoma, the authors enrolled 29 patients who were without local disease recurrence or distant metastasis. The mean follow-up was 93 months. Complications, functional outcomes, and quality of life scores were assessed. Risk factors were analyzed, including the dose-volume histogram of the femoral head.

RESULTS

Femoral head necrosis occurred in approximately 37% of patients, pelvic fractures were reported in 48% of patients, and neurological deficits were noted in 52% of patients. Femoral head necrosis was found to be significantly more prevalent among patients with periacetabular tumors (P = .018). The dose-volume histogram of the femoral head indicated tolerable volume percentages of the femoral head to be <33% for 40 grays (relative biological effectiveness) and 16% for 60 grays ( relative biological effectiveness). The mean Musculoskeletal Tumor Society score and Toronto Extremity Salvage Score were 53% and 64%, respectively, and the mean EuroQol 5 dimensions questionnaire index was 0.587. Patients aged >50 years and those with periacetabular tumors were found to have significantly lower Toronto Extremity Salvage Scores.

CONCLUSIONS

Femoral head necrosis, pelvic fracture, and nerve damage are common complications with the use of CIRT for pelvic bone sarcoma. To prevent femoral head necrosis, the radiation dose to the femoral head should be kept below the estimated tolerance curve presented in the current study. The functional outcome is nearly equivalent to that of surgery. CIRT may be a promising alternative to surgery for patients with unresectable pelvic bone sarcoma.

Pelvic bone tumor resection: what a radiologist needs to know

Pelvic bone tumors present a diagnostic and therapeutic challenge. Due to the deep anatomic location and resultant late clinical presentation, pelvic bone tumors tend to be large and located in close proximity to pelvic viscera as well as vital neurovascular structures. Operative management of pelvic bone tumors is indicated for a variety of orthopedic oncologic conditions. In general, limb-sparing pelvic resection rather than hemipelvectomy with amputation of the ipsilateral limb is considered when a functional limb can be preserved without compromising the surgical margins. There are various options for pelvic resection and reconstruction, and the selection depends on tumor histology, anatomic location, and extent. The decision regarding choice of surgical procedure and reconstruction method for a pelvic bone tumor requires a thorough knowledge of the pelvic anatomy, and careful inspection of the anatomic extent. The surgical plan must strike a balance between acceptable functional outcome and acceptable morbidity. In this review, we describe the different types of pelvic resection techniques, and the vital role preoperative imaging plays in defining the anatomic extent of a pelvic bone tumor and subsequent surgical planning.

Outcomes following periacetabular tumor resection: A 25-year institutional experience

BACKGROUNDS AND OBJECTIVES

Following tumor resection involving the acetabulum (periacetabular), various methods of reconstruction exist. The objective of this study was to analyze functional outcomes and complication rates by extent of periacetabular tumor resection, as well as by method of reconstruction.

METHODS

Twenty-three patients underwent periacetabular resection for a primary pelvic bone tumor from 1993-2018 at a single institution. Complications were documented and functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) scoring system.

RESULTS

Mean age was 42.8 ± 22.6 years. Mean follow-up was 107 ± 75 months. MSTS scores were highest in patients with allograft reconstruction (80.2%) and lowest in saddle reconstruction (38.0%). MSTS scores were higher in patients with Type II periacetabular resection alone compared with Type II + additional resection (78.6% vs 60.3%; P = .019). Complications were lower in patients with Type II periacetabular resection alone (75% vs 28.6%; P = .036). Complications were highest following allograft reconstruction (78%) and lowest following hemipelvectomy without reconstruction (20%).

CONCLUSION

Patients who underwent allograft/APC or nonsaddle metallic reconstruction experienced the highest functional outcome scores, but also sustained a higher complication rate than patients with hemipelvectomy without reconstruction. Patients with resection of ilium and/or pubis in addition to the periacetabular region had lower functional outcome scores and higher risk for complication.

Biomechanics study of a 3D printed sacroiliac joint fixed modular hemipelvic endoprosthesis

BACKGROUND

Reconstructing pelvic type II + III defect caused by bone tumors is challenging. The purpose of this study was to explore the in vitro biomechanical properties of a reconstructed pelvis after periacetabular resection using three-dimensional (3D) printed sacroiliac joint (SIJ) fixed modular hemipelvic endoprosthesis.

METHODS

Type II/II + III pelvic resection was simulated on an artificial pelvic model. The bilateral acetabulum and pubis were constrained, and the pelvis was maintained in a human physiological standing position. A vertically continuous linear load was applied on the upper face of S1 until obvious unloading or fixed failure occurred. A noncontact optical 3D strain measuring system was used to measure the strains and displacements at the selected area.

FINDINGS

The strain at the points of interest did not obviously differ between the intact and reconstructed pelvis models. The difference in the displacement on the reconstructed side was 0.237 mm, and that on the contralateral side was 0.245 mm. The maximum differences in the displacement at the acetabulum were 0.209 mm (vertical) and 0.324 mm (horizontal). A crack at the superior rim of the contralateral acetabulum occurred, and failure loading of 7.126 kN.

INTERPRETATION

The prosthesis in this study showed satisfactory mechanical properties and structural stability. According to the mechanical evaluations, the 3D printed sacroiliac-stabilized hemipelvic endoprosthesis can be used to reconstruct a stable acetabular structure, and there was little influence on the mechanical properties of the surrounding bone structures. The prosthesis design is reasonable, and the mechanical distribution on the reconstructed side was similar to that on the contralateral side.

Extra-articular resection for bone sarcomas involving the hip joint

AIM

The aim of this study was to determine the oncologic, functional, and clinical outcomes after the extra-articular resection and limb-salvage reconstruction of the hip joint.

METHODS

A retrospective study of 34 patients who underwent extra-articular resection of the hip joint for bone sarcomas between 1996 and 2016 was conducted. The primary tumor site was pelvis in 26 patients (76%) and femur in eight (24%).

RESULTS

The surgical margins achieved were clear in 31 (91%) patients, and seven (21%) patients developed local recurrence; mostly occurring in pelvic tumors (n = 6). The 3-year overall survival was 63% with a median follow-up of 38 months (range, 5-219), which showed no statistical difference in tumor location. The most common complication was deep infection (n = 7) and dislocation (n = 7), mostly seen in pelvic tumors. Implant failure was seen in two patients with pelvic tumors, while no failure was noted in patients with femoral tumors. The median Musculoskeletal Tumour Society score was 69%; 67% for pelvic tumors and 73% for femoral tumors (P = .535).

CONCLUSION

Despite complex surgery, extra-articular resection of the hip joint can achieve oncologically and functionally acceptable outcomes. While tumors of the pelvis are associated with a higher incidence of infection and local recurrence after resection, resection of tumors involving the femur are well tolerated.

Surgical treatment for pelvic Ewing sarcoma: What is a safe and functional acetabular reconstruction when combined with modern multidisciplinary treatments?

PURPOSE

The purpose of this study was to clarify which local treatment is oncologically and functionally effective in pelvic Ewing sarcoma (ES).

METHODS

A consecutive series of patients who underwent pelvic resections and acetabular reconstructions after chemotherapy between 1986 and 2016 at a supra-regional center were evaluated.

RESULTS

The cohort consisted of 35 patients. The 5-year overall survival (OS) and local recurrence-free survival (LRFS) was 61% and 72%, respectively. Preoperative radiotherapy (RT) and surgery provided an excellent/good histological response in 92% and achieved significantly better OS (5 years, 64%) and LRFS (5 years, 100%) than surgery alone or surgery with postoperative RT. The Musculoskeletal Tumor Society functional scores were significantly better in patients with hip transposition than those with structural reconstructions (74% vs 57%; P = .031) using custom-made prostheses, irradiated autografts, and ice-cream cone prostheses. These scores were significantly lower if patients had deep infection (P = .035), which was the most common complication (28%) in structural reconstructions but did not occur in hip transposition even when performed after preoperative RT.

CONCLUSION

Acetabular reconstruction with hip transposition resulted in no deep infection and superior function in patients with pelvic ES even when combined with preoperative RT, which improved tumor necrosis and rate of local control and survival.

The usefulness of wide excision assisted by a computer navigation system and reconstruction using a frozen bone autograft for malignant acetabular bone tumors: a report of two cases

Background

Difficult resection of tumors from regions with complex local anatomy, such as the pelvis and sacrum, is likely to result in inadequate surgical margins (intralesional or marginal); this is because three-dimensional osteotomy is difficult particularly around the acetabulum. Additionally, removal of the joint makes reconstruction very difficult; thus, retention of good function also becomes difficult. In musculoskeletal oncology, computer navigation systems are still not widely used to prevent tumor-positive margins. We performed wide excision with guidance from a computer navigation system and reconstruction using frozen bone autografts for malignant pelvic bone tumors in two patients, and we obtained excellent functional and oncological outcomes. Here we present these patients and discuss our approach.

Case presentation

Case 1: A 12-year-old girl presented with Ewing sarcoma of the left pelvis (PI-II). We performed wide excision assisted by a computer navigation system with the osteotomy of the load surface of acetabulum and reconstruction using a frozen bone autograft. At the final follow-up, she showed excellent function and was alive without the disease. Moreover, she did not have osteoarthritis of the left hip joint.

Case 2: A 71-year-old woman presented with dedifferentiated chondrosarcoma of the right pelvis (PII-III). We performed wide excision assisted by a computer navigation system with osteotomy avoiding load surface of the acetabulum and reconstruction using a frozen bone autograft; there was no tumor at the load surface. At the final follow-up, she showed good function, was alive without the disease, and did not have osteoarthritis of the left hip joint.

Conclusions

Wide excision assisted by a computer navigation system and reconstruction using a frozen bone autograft are very useful for the management/treatment of extremely difficult cases such as malignant pelvic bone tumors, particularly those including the acetabulum.

[Progress of reconstruction in bone tumor surgery]

Bone tumor surgery involves tumor resection and subsequent reconstruction. With the development of surgical technique and new material, there is a great step toward bone and joint reconstruction in bone tumor surgery. Generally speaking, there are two major reconstructive methods including bio-reconstruction and mechanical reconstruction. In addition, three-dimensional printed prosthesis has been widely applied in the field of bone tumor surgery. The short-term result is encouraged; however, long-term results and related complications are seldom reported.

Reconstruction of the hip after resection of periacetabular oncological lesions: a systematic review

Aims

Reconstruction of the acetabulum after resection of a periacetabular malignancy is technically challenging and many different techniques have been used with varying success. Our aim was to prepare a systematic review of the literature dealing with these techniques in order to clarify the management, the rate of complications and the outcomes.

Patients and Methods

A search of PubMed and MEDLINE was conducted for English language articles published between January 1990 and February 2017 with combinations of key search terms to identify studies dealing with periacetabular resection with reconstruction in patients with a malignancy. Studies in English that reported radiographic or clinical outcomes were included. Data collected from each study included: the number and type of reconstructions, the pathological diagnosis of the lesions, the mean age and follow-up, gender distribution, implant survivorship, complications, functional outcome, and mortality. The results from individual studies were combined for the general analysis, and then grouped according to the type of reconstruction.

Results

A total of 57 studies met the inclusion criteria and included 1700 patients. Most lesions were metastatic (41%), followed by chondrosarcoma (29%), osteosarcoma (10%), Ewing’s sarcoma (7%), and multiple myeloma (2%). The techniques of reconstruction were divided into seven types for analysis: those involving a Harrington reconstruction, a saddle prosthesis, an allograft and allograft prosthesis composite, a pasteurised autograft, a porous tantalum implant, a custom-made prosthesis and a modular hemipelvic reconstruction. The rate of complications was 50%, with infection (14%) and instability (8%) being the most common. Mortality data were available for 1427 patients (84%); 50% had died of disease progression, 23% were alive with disease, and 27% had no evidence of disease at a mean follow-up of 3.4 years (0 to 34).

Conclusion

Both the rate of complications and mortality are high following resection of oncological periacetabular lesions and reconstruction. Many types of reconstruction have been used with unique challenges and complications for each technique. Newer prostheses, including custom-made prostheses and porous tantalum implants and augments, have shown promising early functional and radiographic outcomes.

Cite this article: Bone Joint J 2018;100-B(1 Supple A):22–30.

Postoperative infections after limb-sparing surgery for primary bone tumors of the pelvis: Incidence, characterization and functional impact

INTRODUCTION

Surgical site infections (SSI) represent the most common postoperative complication after limb sparing surgery for primary malignant bone tumors, with incidence ranging from 10 to 47%. There is no consensus concerning about the optimal surgical strategy, or the adequate antibiotic prophylaxis in pelvic resections. A greater knowledge of these infections and their surgical trajectories seem essential to obtain.

MATERIALS AND METHODS

We retrospectively studied 45 cases of pelvic resection, including at least the periacetabular zone 2 of Enneking, performed between 1989 and 2013 in the same center. Infection rate, risk factors and surgical trajectories were analyzed. The impact of a postoperative infection on the quality of life and functional recovery was evaluated by the Musculoskeletal Tumor Society scoring system (MSTS).

RESULTS

Sixteen patients presented a SSI in the first post-operative year (35.6%). We found as risk factors the pre-operative ASA score, the age at surgery and the number of packed red cells transfused during surgery. In case of failure of an initial washout, an iterative procedure is responsible for a high failure rate of 88.9%. Irrespective of the type of reconstruction, our functional results show that this surgery is often a source of handicap with a MSTS score of 13.77 in infected patients versus 17.70 in non-infected patients, at two-year follow-up.

DISCUSSION

In case of failure of an initial wash, prosthetic material must be removed and a hip transposition procedure should be preferred to a second-look surgery. Concerning prophylactic antibiotherapy, a dual therapy for at least 48 h after surgery should probably be preferred.

Reconstruction After Hemipelvectomy With the Ice-Cream Cone Prosthesis: What Are the Short-term Clinical Results?

BACKGROUND

Reconstruction after internal hemipelvectomy resection likely provides better function than hindquarter amputation. However, many reconstruction methods have been used, complications with these approaches are common, and function often is poor; because of these issues, it seems important to investigate alternative implants and surgical techniques.

QUESTIONS/PURPOSES

The purposes of this study were (1) to identify the frequency of surgical site complications and infection associated with the use of the Ice-Cream Cone prosthesis for reconstruction after hemipelvectomy for oncological indications; (2) to evaluate the Musculoskeletal Tumor Society (MSTS) outcomes scores in a small group of patients treated with this implant in the short term; and (3) to quantify the surgical margins and frequency of local recurrence in the short term in this group of patients.

METHODS

Between 2008 and 2013, one center performed a total of 27 internal hemipelvectomies for oncological indications. Of those, 23 (85%) were treated with reconstruction. Our general indications for reconstruction were patients whose pelvic stability was affected by the resection and whose general condition was sufficiently strong to tolerate the reconstructive procedure. Of those patients undergoing reconstruction, 14 (61%) were treated with an Ice-Cream Cone-style implant (Coned^®; Stanmore Worldwide Ltd, Elstree, UK; and Socincer^® custom-made implant for the pelvis, Gijón, Spain), whereas nine others were treated with other implants or allografts. The indications during this time for using the Ice-Cream Cone implant were pelvic tumors affecting the periacetabular area without iliac wing involvement. Of those 14, 10 were available for followup at a minimum of 2 years (median, 3 years; range, 2-5 years) unless a study endpoint (wound complication, infection, or local recurrence) was observed earlier. Study endpoints were ascertained by chart review performed by one of the authors.

RESULTS

Surgical site complications occurred in five patients. Of those, two developed superficial infections with necrosis, two developed deep infections, and one patient developed wound necrosis without apparent infection. No prostheses were removed as a result of these complications [corrected]. Median MSTS score was 19 out of 30 when 0 is the worst possible result and 30 a perfect function and emotional status. Five of seven primary tumors had wide margin surgery and three of seven developed local recurrences by the end of the followup.

CONCLUSIONS

Pelvic reconstruction with the Ice-Cream Cone prosthesis yielded fair functional results at short-term followup. Longer term surveillance is called for to see whether this implant will represent an improvement over available reconstructive alternatives such as allograft, custom-made implants, and saddle prostheses. We are cautiously optimistic and continue to use this implant when we need to reconstruct the periacetabular area in patients without Enneking Zone 1 involvement.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Oncological and surgical outcome after treatment of pelvic sarcomas

Background and objectives

Treatment of pelvic tumors remains challenging due to complex anatomy, poor oncological outcome and high complication rates. We sought to investigate the long-term oncological and surgical outcome of these patients.

Methods

Between 1980 and 2012, 147 patients underwent surgical treatment for pelvic sarcoma. Histological diagnosis was Chondrosarcoma in 54, Ewing’s Sarcoma/PNET in 37, Osterosarcoma in 32 and others in 24 patients. Statistical analysis for the evaluation of oncological and surgical outcome was performed by applying Cox proportional hazards regression and Fine-Gray regression models for competing risk (CR) endpoints.

Results

The estimated overall survival (OS) to death was 80%, 45% and 37% at 1, 5 and 10 years, respectively. Univariate analyses revealed a statistically significant unadjusted influence of age age (p = 0.038; HR = 1.01), margin (p = 0.043; HR = 0.51) and grade (p = 0.001; HR = 2.27) on OS. Considering the multivariable model, grade (p = 0.005; HR = 3.04) and tumor volume (p = 0.014; HR = 1.18) presented themselves as independent prognostic factors on OS. CR analysis showed a cumulative incidence for major complication of 31% at 5 years. Endoprosthetic reconstruction had a higher risk for experiencing a major complication (p<0.0001) and infection (p = 0.001).

Conclusions

Pelvic resections are still associated with a high incidence of complications. Patients with pelvic reconstruction and high volume tumors are especially at risk. Consequently, a cautious decision-making process is necessary when indicating pelvic reconstruction, although a restrictive approach to pelvic reconstruction is not necessarily reasonable when the other option is major amputation.

The pedicle screw-rod system is an acceptable method of reconstructive surgery after resection of sacroiliac joint tumours

Hemipelvic resections for primary bone tumours require reconstruction to restore weight bearing along anatomic axes. However, reconstruction of the pelvic arch remains a major surgical challenge because of the high rate of associated complications. We used the pedicle screw-rod system to reconstruct the pelvis, and the purpose of this investigation was to assess the oncology, functional outcome and complication rate following this procedure. The purpose of this study was to investigate the operative indications and technique of the pedicle screw-rod system in reconstruction of the stability of the sacroiliac joint after resection of sacroiliac joint tumours. The average MSTS (Musculoskeletal Tumour Society) score was 26.5 at either three months after surgery or at the latest follow-up. Seven patients had surgery-related complications, including wound dehiscence in one, infection in two, local necrosis in four (including infection in two), sciatic nerve palsy in one and pubic symphysis subluxation in one. There was no screw loosening or deep vein thrombosis occurring in this series. Using a pedicle screw-rod after resection of a sacroiliac joint tumour is an acceptable method of pelvic reconstruction because of its reduced risk of complications and satisfactory functional outcome, as well as its feasibility of reconstruction for type IV pelvis tumour resection without elaborate preoperative customisation.

Level of evidence: Level IV, therapeutic study.

Reconstruction of periacetabular tumours with saddle prosthesis or custom-made prosthesis, functional results and complications

Reconstruction after resection of pelvic tumours is a major challenge. We report the outcomes and complications of 7 patients who underwent limb salvage following type II or type II, III pelvic resection and reconstruction using a saddle prosthesis or custom-made hemipelvic prosthesis. In our opinion, reconstruction using custom-made prostheses is better than placement of saddle prostheses because of a lower risk of complications and improved functional outcomes.

Clinical Outcomes of Surgical Treatments for Primary Malignant Bone Tumors Arising in the Acetabulum

The functional and oncologic results of eighteen patients with primary malignant periacetabular tumors were reviewed to determine the impact of surgical treatment. The reconstruction procedures were endoprosthesis (11), hip transposition (4), iliofemoral arthrodesis (2), and frozen bone autograft (1). After a mean follow-up of 62 months, 13 patients were alive and 5 had died of their disease; the 5-year overall survival rate was 67.2%. The corresponding mean MSTS scores of patients with endoprosthesis (11) and other reconstructions (7) were 42% and 55% (49%, 68%, and 50%), respectively. Overall, postoperative complications including deep infection or dislocation markedly worsened the functional outcome. Iliofemoral arthrodesis provided better function than the other procedures, whereas endoprosthetic reconstruction demonstrated poor functional outcome except for patients who were reconstructed with the adequate soft tissue coverage. Avoiding postoperative complications is highly important for achieving better function, suggesting that surgical procedures with adequate soft tissue coverage or without the massive use of nonbiological materials are preferable. Appropriate selection of the reconstructive procedures for individual patients, considering the amount of remaining bone and soft tissues, would lead to better clinical outcomes.

Bernese Periacetabular Osteotomy in a Hip Extra-Articular Resection Followed by Reconstruction Using an Extracorporeal Irradiated Acetabulum Autograft with Megaprosthesis, for Proximal Femur Osteosarcoma in a Pediatric Patient

Osteosarcoma is the most common primary malignant tumour of bone. The oncologic surgery of a proximal femur osteosarcoma affecting the hip joint can be very challenging. We present an 8-year-old boy with a 5-month history of right hip pain. Radiographs and magnetic resonance imaging (MRI) showed a lytic lesion of the proximal femur extending 13 cm to the diaphysis. Histological evaluation was consistent with high-grade osteoblastic osteosarcoma. After completing chemotherapy we performed an extra-articular resection of the hip. Reconstruction was accomplished by reimplanting the acetabulum after irradiation and modular proximal femur megaprosthesis. Endoprosthetic reconstruction following proximal femur resection is a good treatment alternative achieving good postoperative function. Extra-articular resection of the hip using a periacetabular osteotomy technique enabled us to achieve wide margins and leave an intact posterior column to optimize acetabular reconstruction stability. Extracorporeal irradiation and reimplantation is a valuable treatment option in a situation such as this where allograft geometric fit is a priority. We conclude that an extra-articular resection of the hip, followed by reconstruction with an extracorporeally irradiated acetabulum and a proximal femur modular megaprosthesis, is a useful combined treatment option for malignant lesions involving the hip joint, especially in paediatric patients.

Resection and reconstruction of pelvic bone tumors

The objective of this study was to assess outcome and recurrence rate after limb-salvage surgery with reconstruction for pelvic bone tumors and analyze complications and their relationship with surgery. The authors analyzed 129 patients followed for a mean of 6 years (range, 2-19 years). Chondrosarcoma was the most frequent histotype. Thirty-one cases with no acetabular involvement were reconstructed with allograft only. Acetabular resections were reconstructed with allograft prosthetic composite (n=60), allograft only (n=11), trabecular metal components (n=2), prosthesis only (n=10), saddle prosthesis (n=11), and iliofemoral arthrodesis (n=1). Margins were wide (n=94), wide contaminated (n=22), marginal (n=7), and intralesional (n=6). Oncologic outcomes were as follows: 75 patients were continuously disease free, 6 were disease free after treatment of relapse, 13 were alive with disease, 28 were dead of disease, and 5 were dead of other causes. Survival was 66% at 10 years. Local recurrence rate of malignant tumors was 22.1% and was not statistically influenced by margins (P=.140) or site (P=.933). Metastasis rate was 32.8%. Deep infection was observed in 30 (23.6%) cases, with no statistical difference between reconstructions with and without allograft (P=.09). Final external hemipelvectomy was performed in 16 cases. Newer techniques of reconstruction using stemmed acetabular cups or porous metal components combined with allograft are now available. Local control and satisfactory survival is achievable long term in patients with pelvic tumors, but this surgery implies a high rate of complications. Infection is a major complication, not influenced by the use of allografts. Amputation is rarely needed.

[Pelvic reconstructions after bone tumor resection]

The three more frequent primitive malignant bone tumour which concerned the iliac bone are chondrosarcoma, following Ewing sarcoma and osteosarcoma. Wide resection remains the most important part of the treatment associated with chemotherapy for osteosarcoma and the Ewing sarcoma. Iliac wing resections and obdurate ring don't required reconstruction. However, acetabular resections and iliac wing resection with disruption of the pelvic ring required reconstruction to provide acceptable functional result. Acetabular reconstruction remains high technical demanding challenge. After isolated acetabular resection or associated to obdurate ring, our usual method of reconstruction is homolateral proximal femoral autograft and total hip prosthesis but it is possible to also used : saddle prosthesis, Mac Minn prosthesis with auto or allograft, modular prosthesis or custom made prosthesis, massive allograft with or without prosthesis and femoro-ilac arthrodesis. After resection of the iliac wing plus acetabulum, reconstruction can be performed by femoro-obturatrice and femora-sacral arthrodesis, homolateral proximal femoral autograft and prosthesis, femoral medialisation, massive allograft and massive allograft. Carcinological results are lesser than resection for distal limb tumor, local recurrence rate range 17 to 45%. Functional results after Iliac wing and obdurate ring are good. However, acetabular reconstruction provide uncertain functional results. The lesser results arrive after hemipelvic or acetabular and iliac wing resection-reconstruction, especially when gluteus muscles were also resected. The most favourable results arrive after isolated acetabular or acetabular plus obturateur ring resection-reconstruction.

Infection after surgical resection for pelvic bone tumors: an analysis of 270 patients from one institution

BACKGROUND

Surgical treatment of pelvic tumors with or without acetabular involvement is challenging. Primary goals of surgery include local control and maintenance of good quality of life, but the procedures are marked by significant perioperative morbidity and complications.

QUESTIONS/PURPOSES

We wished to (1) evaluate the frequency of infection after limb salvage surgical resection for bone tumors in the pelvis; (2) determine whether infection after these resections is associated with particular risk factors, including pelvic reconstruction, radiotherapy or chemotherapy, type of resection, and age; and (3) analyze treatment of these infections, particularly with respect to the need of additional surgery or hemipelvectomy.

METHODS

From 1975 to 2010, 270 patients with pelvic bone tumors (149 with chondrosarcoma, 40 with Ewing's sarcoma, 27 with osteosarcoma, 18 with other primary malignant tumors, 11 with metastatic tumors, and 25 with primary benign tumors) were treated by surgical resection. Minimum followup was 1.1 years (mean, 8 years; range, 1-33 years). The resection involved the periacetabular area in 166 patients. In 137 patients reconstruction was performed; in 133 there was no reconstruction. Chart review ascertained the frequency of deep infections, how they were treated, and the frequency of resection arthroplasty or hemipelvectomies that occurred thereafter.

RESULTS

A total of 55 patients (20%) had a deep infection develop at a mean followup of 8 months. There were 20 infections in 133 patients without reconstruction (15%) and 35 infections in 137 patients with reconstruction (26 %). Survivorship rates of the index procedures using infection as the end point were 87%, 83%, and 80% at 1 month, 1 year, and 5 years, respectively. Infection was more common in patients who underwent pelvic reconstruction after resection (univariate analysis, p = 0.0326; multivariate analysis, p = 0.0418; odds ratio, 1.7718; 95% CI, 1.0243-3.0650); no other risk factors we evaluated were associated with an increased likelihood of infection. Despite surgical débridements and antibiotics, 16 patients (46%) had the implant removed and five (9%) underwent external hemipelvectomy (four owing to infection and one as a result of persistent infection and local recurrence).

CONCLUSIONS

Infection is a common complication of pelvic resection for bone tumors. Reconstruction after resection is associated with an increased risk of infection compared with resection alone, without significant difference in percentage between allograft and metallic prosthesis. When infection occurs, it requires removal of the implant in nearly half of the patients who have this complication develop, and external hemipelvectomy sometimes is needed to eradicate the infection.

Extracapsular wide resection of a femoral neck osteosarcoma and its reconstruction using a pasteurized autograft-prosthesis composite: A case report

The requirement for an extracapsular resection is indicated for malignant bone tumors that have disseminated intracapsularly. Extracapsular resections are often performed for malignant tumors arising from the knee joint, but there are relatively few studies that have described an extracapsular resection of a tumor arising from the hip joint. The present study describes a case of extracapsular wide resection of the hip joint using rotational acetabular osteotomy. The patient was a 17-year-old female and the diagnosis was an osteoblastic osteosarcoma with a pathological fracture of the femoral neck. The joint was reconstructed using an allograft-implant composite graft and total hip arthroplasty. Although the patient presented a slight Trendelenburg gait, no recurrence or metastases were identified during a follow-up period of 3 years. The clinical features and surgical procedure of the case are described.

Constrained total hip megaprosthesis for primary periacetabular tumors

BACKGROUND

Limb-salvage reconstruction for periacetabular malignant tumors is one of the most challenging problems in orthopaedic oncology. Reconstructive options include resection arthroplasty, endoprosthesis, allograft, recycled autobone graft, arthrodesis, and pseudarthrosis. However, no standard procedure exists because of rarity and clinical variability of the disease. We previously developed a megaprosthetic system with a constrained total hip mechanism (C-THA).

QUESTIONS/PURPOSES

We evaluated (1) survival of patients and C-THA; (2) postoperative function; and (3) complications.

METHODS

We retrospectively reviewed 25 patients with primary periacetabular tumors treated using C-THA between 1985 and 2009. There were 18 male and seven female patients with a median age of 44 years (range, 16-72 years). They included 11 chondrosarcomas, eight osteosarcomas, two giant cell tumors of bone (one locally aggressive benign, one malignant), and others in four. Surgical margin was wide in 18 patients, marginal in five, and intralesional in two. The minimum postoperative followup for survivors was 32 months (median, 163 months; range, 32-285 months).

RESULTS

The 10-year overall survival rate of all patients was 47%. C-THA implants survived in 19 of 25 patients at last followup. Twenty-one patients acquired ambulatory activity. There were seven local recurrences, resulting in hemipelvectomy in one patient. Postoperative complications included deep infection in eight of the 25 patients, dislocation in four, and aseptic loosening in two, necessitating five revision surgeries and three implant removals.

CONCLUSIONS

Our observations suggest C-THA using an acetabular reconstruction cup is a useful reconstructive option after resection of periacetabular malignant tumors despite frequent postoperative complications.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Poor long-term clinical results of saddle prosthesis after resection of periacetabular tumors

BACKGROUND

The saddle prosthesis originally was developed to reconstruct large acetabular defects in revision hip arthroplasty and was used primarily for hip reconstruction after periacetabular tumor resections. The long-term survival of these reconstructions is unclear.

QUESTIONS/PURPOSE

We therefore examined the long-term function, complications, and survival in patients treated with saddle prostheses after periacetabular tumor resection.

PATIENTS AND METHODS

Between 1987 and 2003 we treated 17 patients with a saddle prosthesis after periacetabular tumor resection (12 chondrosarcomas, three osteosarcomas, one malignant fibrous histiocytoma, one metastasis). During followup, 11 patients died, resulting in a median overall survival of 49 months (95% CI, 30-68 months). The remaining six patients were alive without disease (mean followup, 12.1 years; range, 8.3-16.8 years). In one patient the saddle prosthesis was removed after 3 months owing to dislocation and infection. We obtained SF-36 questionnaires, Toronto Extremity Salvage Scores (TESS), and Musculoskeletal Tumor Society (MSTS) scores.

RESULTS

Thirteen of 17 patients used walking assists for mobilization at last followup: eight patients required two crutches, five needed one crutch, and one did not use any walking aids. The other three patients were not able to mobilize independently and only made bed to chair transfers. The mean hip flexion in the six surviving patients was 60° (range, 40°-100°) at last followup. Local complications were seen in 14 of the 17 patients: nine wound infections, seven dislocations, and two leg-length discrepancies requiring additional surgery. In the five surviving patients with their index prosthesis still in situ, the mean MSTS score at long-term followup was 47% (range, 20%-77%), the mean TESS score was 53% (range, 41%-67%), and the mean composite SF-36 physical and mental component summaries were 43.9 and 50.6, respectively.

CONCLUSION

Reconstruction with saddle prostheses after periacetabular tumor surgery has a high risk of complications and poor long-term function with limited hip flexion; therefore, we no longer use the saddle prosthesis for reconstruction after periacetabular tumor resections.

Study of treatment using percutaneous acetabuloplasty and interstitial implantation of (125)I seeds for patients with metastatic periacetabular tumors

Background

The periacetabular area is one of the primary sites of metastatic tumors, which often present as osteolytic bone destruction. Bone destruction in the acetabulum caused by metastatic tumors will cause hip pain and joint dysfunction. It results in decreased quality of life for patients. The aim of our study was to explore the clinical effect of metastatic periacetabular tumors treated with percutaneous cementoplasty and interstitial implantation of ¹²⁵I seeds.

Methods

A retrospective analysis was performed on 24 patients with metastatic periacetabular tumors who underwent combined therapy of percutaneous acetabuloplasty and interstitial implantation of ¹²⁵I seeds between February 2003 and June 2011. There were 13 males and 11 females aged 19–80 years with a mean age of 57.3. The primary tumor site was the lung in eight cases, the breast in six, the prostate cancer in eight, and the liver in two. The amount of implanted ¹²⁵I seeds was 12–20 seeds/person, with a mean of 16.5 seeds/person, and the matching peripheral dosage (MPD) was 80~100Gy. Routine postoperative chemotherapy and other combined treatments were applied to patients after the surgical operation. Changes in the Karnofsky Score(KPS), Harris Hip Score(Harris), and Visual Analog Scale(VAS) were observed during the follow-up period.

Results

The 24 patients’ operations were all successful. No major complications occurred. Complete pain relief was achieved in 58% (14 of 24) of patients, and pain reduction was achieved in the 42% remaining (10) patients. The mean duration of pain relief was 8.3 months. Pain recurred in one patient 3 months after surgery. Six patients had died and 18 patients were alive at the time of the 1-year follow-up. Comparing the KPS, Harris and VAS scores pre- and postoperativelyat 1, 6, and 12 months, the combined therapy method was significantly effective in metastatic periacetabular tumor patients (P<0.05).

Conclusions

Percutaneous cementoplasty with interstitial implantation of ¹²⁵I seeds is an effective treatment method for metastatic periacetabular tumor patients, providing tumor resistance, pain relief, increased bone stability, and improved quality of life for patients.

A new technique of endoprosthetic replacement for osteosarcoma of proximal femur with intra-articular extension

INTRODUCTION

Osteosarcoma is the most common primary malignant tumour of bone and commonly involved sites are the distal femur, proximal tibia, and humerus. Osteosarcoma of proximal femur usually arises at the metaphysis and articular cartilage acts as a relative barrier to tumour spread, with extension into the hip joint being extremely rare.

PRESENTATION OF CASE

A previously fit and well sixteen-year-old male presented with a 2month history of right hip pain and a limp. Plain radiographs and magnetic resonance imaging (MRI) showed an expansile lesion in the right femoral neck, extending 16cm distally from the proximal femoral articular surface through the intertrochanteric region into the upper right femoral shaft. There was also clear evidence of intra-articular extension into the acetabulum.

DISCUSSION

Endoprosthetic replacement following resection is a good treatment option for proximal femoral tumours due to the low complication rate and achievement of good postoperative function. However, treatment of a proximal femoral lesion with intra-articular involvement by prosthetic reconstruction is challenging. We report a patient who presented with osteosarcoma of the proximal femur extending into the hip joint and describe the technique of en-bloc extra-articular resection of the acetabulum and proximal femur with reconstruction using a custom made prosthesis.

CONCLUSION

We conclude that extra-articular resection and endoprosthetic reconstruction using a coned hemi-pelvic implant with fluted stem and a modular femoral implant is a useful treatment option in the management of a proximal femoral lesion involving the hip-joint. It allows adequate tumour clearance and stable reconstruction for rapid post-operative recovery with early mobilisation.

Biomechanical concept and clinical outcome of dual mobility cups

Dual mobility cup systems in total hip arthroplasty consist of a metal back with a non-constrained liner, in which a constrained standard head articulates. While superior stability of such implants in comparison with standard total hip replacements is assumed, it is the purpose of this study to outline the biomechanical concept of dual mobility cups and to describe implant survival and dislocation rate based on the series published in the English-speaking and Francophone literature. A growing body of evidence indicates reduced dislocation rates in primary and revision total hip arthroplasty and in selected tumour cases. The limited availability of studies evaluating long-term implant survival and existing concerns with regard to increased wear rates and aseptic loosening, leads to the conclusion that such implants have to be used with prudence, particularly in standard primary hip arthroplasty and in young patients.

Primary tumor of the periacetabular region: resection and reconstruction using a segmental ipsilateral femur autograft

INTRODUCTION

Bone reconstruction, after periacetabular tumour removal, is a complex procedure that carries a high morbidity rate and can result in poor clinical outcomes. Among the available options, the Puget pelvic resection-reconstruction procedure uses an autograft from the ipsilateral proximal femur to restore the anatomical and mechanical continuity of the pelvic ring before inserting an acetabular implant. HYPOTHESIS AND GOALS: This reconstruction technique satisfactorily restores the pelvic anatomy such that functional results and morbidity are comparable to alternative reconstruction techniques.

PATIENTS AND METHODS

This was a retrospective study of 10 patients with an average age of 38.2 years (range 19 to 75) at the surgical procedure (performed between 1986 and 2007). There were five chondrosarcomas, three Ewing tumours, one plasmacytoma and one giant cell tumour. The position of the hip centre of rotation after reconstruction and autograft integration were evaluated on radiographs. Functional results were evaluated through the Musculoskeletal Tumor Society (MSTS) score and the Postel and Merle d'Aubigné (PMA) score.

RESULTS

At the time of review, one patient was lost to follow-up and four had died. On radiographs, the hip centre of rotation after reconstruction was higher by a median value of 15 mm (range 5 to 35) and more lateral by a median value of 6mm (range -5 to 15). Upon evaluation of radiographs at a median time of 40 months (range 6 to 252 months), the autograft was completely integrated in five patients and partially integrated in three patients (two patients had a local recurrence). There were no cases of autograft fracture or non-union at the junctions of the graft. The median MSTS score was 25 out of 30 (range 20 to 29), or 83% (range 67 to 97%) at the median clinical follow-up of 82 months (range 49 to 264). The median PMA score was 13 out of 18 (range 12 to 18). All living patients were walking without assistance. Five patients required nine surgical revisions. Seven were attributed directly or indirectly to local recurrence; one revision was performed because of instability and one because of early acetabular loosening at 9 months.

CONCLUSION

This challenging procedure provides satisfactory mechanical and anatomical results, while restoring hip anatomy and function. The primary cause of failure in this series was local recurrence of the tumour, which highlights the need to carefully select the indications and optimize the surgical tumour resection.

Clinical and functional outcomes of the saddle prosthesis

BACKGROUND

The implantation of a saddle prosthesis after resection of a pelvic tumor has been proposed as a simple method of reconstruction that provides good stability and reduces the surgical time, thus limits the onset of intraoperative complications. There are no studies in the literature of patients evaluated using gait analysis after being implanted with a saddle prosthesis. The present study is a retrospective case review aimed at illustrating long-term clinical and functional findings in tumor patients reconstructed with a saddle prosthesis.

MATERIALS AND METHODS

A series of 15 patients who received pelvic reconstruction with a saddle prosthesis were retrospectively reviewed in terms of clinical, radiographic, and functional evaluations. Two patients were additionally assessed by gait analysis.

RESULTS

Long-term functional follow-up was achieved in only 6 patients, and ranged from 97 to 167 months. Function was found to be rather impaired, as a mean of only 57 % of normal activity was restored. Gait analysis demonstrated that the implant had poor biomechanics, as characterized by very limited hip motion.

CONCLUSIONS

Though the saddle prosthesis was proposed as advance in tumor-related pelvic surgery, the present study indicates that it yields unsatisfactory clinical and functional results due to both clinical complications and the poor biomechanics of the device. The use of a saddle prosthesis in tumor surgery did not provide satisfactory results in long-term follow-up. It is no longer implanted at our institute, and is currently considered a "salvage technique."

Pelvic resections

The complexity of pelvic anatomy and the extent of tumor growth makes treatment of patients with primary bone sarcomas in the pelvis difficult in terms of local control. Before the 1970s, most tumors in the bony pelvis were surgically treated with hindquarter amputation. Currently, improved techniques for clinical staging, adjuvant treatments, evolutions in metallurgy, and development of new surgical techniques make limb-salvage surgery and reconstruction possible alternatives to hemipelvectomy and resection-arthrodesis. The advantages of amputation over resections at the pelvis are a lower incidence of complications, a limited area at risk for recurrence, and a faster recovery time compared with all but the most limited pelvic resections. The disadvantages, especially after periacetabular resections, are leg-length discrepancy and impaired hip and gait function. The indication for limb salvage is the ability to obtain wide margins without compromising survival and function. Although having to resect the sciatic nerve to obtain adequate margins does not always mean that an amputation should be performed, the combination of a major pelvic resection and the functional consequences of sciatic nerve resection results in an extremity usually not worth saving; loss of femoral nerve function does not result in a significant gait disturbance, especially if the hemipelvis is stable. Reconstruction options after major pelvic resections have also evolved, but they remain difficult, especially when the acetabulum is involved.

The anatomy of proximal femoral autografts for pelvic reconstruction: a cadaveric study

PURPOSE

One important reconstruction procedure following pelvic tumor resection is ipsilateral femoral autograft reconstruction in which the autograft is transposed onto the defect and a conventional total hip replacement is implanted in the autograft. The purpose of this study is to provide anatomical evidence for this reconstruction by measurement of proximal femoral autografts.

METHODS

The anatomical study of proximal femoral autografts was performed on thirteen fresh-frozen Chinese male cadavers. Four parameters were measured and included the diameter of the femoral head (DFH), the distance from the apex of the greater trochanter perpendicular to the medial cortex edge of the femoral neck (DAM), the length between the apex of the femoral head and the midpoint of osteotomy line under the lesser trochanter (LAM), and the width of the greater trochanter from anterior to posterior (WG). The correlation between height and each of the various parameters was analyzed using the Spearman's correlation.

RESULTS

The median (first and third quartile) values of the measurements for the above mentioned parameters were 49 mm (48-52.7 mm), 58.5 mm (54.5-60.9 mm), 102 mm (96-105.2 mm) and 48 mm (46.5-51 mm), respectively. There was a positive correlation between height and each of these four parameters (P < 0.05).

CONCLUSIONS

The proximal femoral autograft reconstruction may be a good option after resection of a pelvic tumor because of the provision of biological reconstruction. However, an individual preoperative plan should be carefully performed following evaluating the size of the bone defect after tumor resection and height and width of the remaining greater trochanter prior to conventional hip replacement.

Metastases of the pelvis: does resection improve survival?

Limited data are available to compare the outcome of wide en bloc resection and curettage for pelvic metastases. Previous studies have reported that curettage is associated with high mortality and decreased survival compared to wide resection and have justified consideration of a radical surgical approach to achieve pain palliation and tumor control. In this study, we aimed to evaluate the role of curettage/marginal resection compared to wide en bloc resection for patients with pelvic metastases. The hypothesis was that wide resection does not improve survival even in patients with solitary pelvic metastases.Between 1985 and 2009, twenty-one patients with pelvic metastases were treated with wide resection (12 patients) and curettage/marginal resection (9 patients) and adjuvants. Sixteen patients had solitary pelvic metastases. At a mean of 28 months (range, 2-152 months), we found no difference in survival to death or local recurrence with wide en bloc resection compared to curettage or marginal resection, even in patients with solitary pelvic metastases. The overall survival to death and local recurrence was 30% and 47% at 60 months, respectively. Survival to death of patients treated with wide resection was 18% at 60 months compared to 62% at 60 months of patients treated with curettage/marginal resection; no difference in survival to death between wide resection and curettage/marginal resection was observed even in patients with solitary pelvic metastases. Survival to local recurrence of patients treated with wide en bloc resection was 67% at 36 months compared to 26% at 36 months of patients treated with curettage/marginal resection; this was also not statistically significant. One patient treated with wide resection for a solitary pelvic metastasis had a postoperative complication.