Extra-articular resection is a limb-salvage option for sarcoma involving the hip joint

Composite Reconstruction With Irradiated Autograft Plus Total Hip Replacement After Type II Pelvic Resections for Tumors Is Feasible but Fraught With Complications

BACKGROUND

Malignancies involving the pelvic ring present numerous challenges, especially in the periacetabular area. Extensive resection of the pelvic region without reconstruction can lead to severe functional impairment. Numerous reconstructive options exist, but all have drawbacks. Extracorporeally irradiated autografts are one option for reconstruction after periacetabular resections; they offer the potential advantages of eliminating the risk of allogeneic reactions associated with allografts and preserving local anatomy. However, little is known about the durability and risks of this approach in pelvic reconstruction.

QUESTIONS/PURPOSES

(1) What are the survival rates of the autograft used, and if there is graft loss, what is the extent of this loss? (2) What are the functional outcomes after the implementation of this method? (3) What is the rate and nature of complications associated with this approach?

METHODS

This is a retrospective case series from one subspecialty tumor unit that evaluated patients treated between January 2005 to January 2022. During that time, three surgeons treated 48 patients with Type II resections (defined as resection of periacetabular area). Patients treated with isolated Type II resections were eligible, as were those treated either with Type I+II resections, Type II+III resections, Type I+II+III resections, and Type I+II+III+IV resections. Of those, 21% (10 of 48) were treated primarily with a cone prosthesis, 13% (6 of 48) were treated without femoral reconstruction, 10% (5 of 48) were treated with resection without reconstruction, and 6% (3 of 48) had a THA on the sacrum, leaving 50% (24 of 48) of patients who were treated with femoral and acetabular reconstruction using extracorporeally irradiated autograft and total hip replacement; those patients were potentially eligible for this study. During that time span, we used this approach in all Type II pelvic resection procedures, when a part of the hemipelvis could be preserved without resection (other than Type I+II+III+IV) and where we predicted that there would be sufficient bone stock after tumor removal. Of those, 21% (5 of 24) were lost to follow-up before 2 years, and 13% (3 of 24) died within 2 years with the reconstruction intact and without any reoperation or graft loss, leaving 67% (16 of 24) for analysis here. Demographic characteristics, type of tumor, tumor origin site, type of applied resection, and extent of applied surgical procedure were noted. Of 16 patients, 12 were male, with a mean age of 38 ± 21 years. Tumor types included chondrosarcoma in eight patients, malignant mesenchymal tumor in four patients, osteosarcoma in two patients, and Ewing sarcoma in two patients. Among these, 10 patients had tumors originating from the pelvis, whereas six patients had tumors originating from the proximal femur. We used a Kaplan-Meier estimator to calculate survivorship free from total or partial graft removal at 72 months. To measure functional results, the Musculoskeletal Tumor Society (MSTS) scoring system was utilized at most recent follow-up so as to be able to evaluate the impact of complications (if any) on the ultimate result. The MSTS score ranges from a minimum of 0 points to a maximum of 30 points, where a higher score reflects lower pain and higher functional and emotional capacity. Related complications, time of complications, secondary interventions, and mortality rates were also ascertained from chart review.

RESULTS

Graft survival rate at 72 months after initial reconstruction, free from partial or total graft removal, was 50% (95% CI 26% to 75%). Kaplan-Meier analyses revealed estimated mean time of graft removal as 43 months (95% CI 28 to 58). The graft was protected in eight patients on their final follow-up radiographs. The median (range) MSTS score was 18 (6 to 25) of 30 points at most-recent follow-up (these scores include patients who have had their grafts removed). In all, 15 of 16 patients had 17 complications; 16 were major complications (defined as those substantial enough to result in further surgery or a life- or limb-threatening event). A total of 14 of those 15 patients underwent one or more secondary procedures (a total of 21 unplanned additional procedures were performed in those patients). Deep infection was the most common complication, occurring in eight patients. Prosthesis dislocation occurred in four patients. Three patients developed aseptic acetabular component loosening, two had graft fractures, and one patient developed heterotopic ossification.

CONCLUSION

Composite reconstruction with extracorporeal irradiated autografts plus total hip replacement is a feasible reconstruction technique after Type II pelvic resections, although complications and reoperations were common. Although no reconstruction technique has been proven superior to other alternatives, the high risk of complications and reoperations associated with this technique should be considered when selecting from among possible alternative reconstruction methods.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Extra-articular hip resection with maintenance of pelvic continuity in malignant tumours of the proximal femur with articular invasion

INTRODUCTION

Extra-articular hip resection may be necessary in cases of malignant tumour of the pelvic bone or of the proximal femur invading the hip joint. When the tumour is in the proximal femur, it is possible to resect the acetabulum en bloc by performing a periacetabular osteotomy, but this creates a discontinuity in the pelvic ring with difficult reconstruction and diminished function. Several techniques described recently seek to be as sparing as possible on the pelvic bone by preserving the posterior column or both columns in order to facilitate reconstruction and improve function. However, these still require complex reconstructions and can necessitate intra-pelvic dissection.

TECHNIQUE

We describe here an extra-articular hip resection technique for tumours of the proximal femur invading the joint, with maintenance of pelvic continuity by preserving both columns and the quadrilateral plate of the acetabulum, without intra-pelvic dissection, that can be performed on patients in whom the medial wall of the acetabulum is thick enough. Our preliminary assessments have included studies on dry bone and imaging analyses. The technique was first tested on a single cadaver pelvis (encompassing 2 hips) and subsequently performed on a patient with a pathological fracture of the femoral neck due to osteosarcoma secondary to Paget's disease.

CONCLUSIONS

Further clinical applications are essential to evaluate the overall effectiveness, safety and impact on patient functionality of this experimental technique.

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.

Proximal femur versus acetabular extra-articular resection of the hip joint for primary malignant bone tumors: a retrospective comparative review of 33 cases

Introduction

Extra-articular resection (EAR) of the hip joint is prone to significant complications and morbidity. Thus, this study evaluates the cumulative incidences and main reasons of reoperation following EAR of primary malignant bone tumors (PMBT) of the hip to determine whether the outcomes are different between EAR of the pelvis and that of the proximal femur.

Patients and methods

Thirty-three patients presented with a PMBT of the proximal femur or pelvis were included in this study. Among all PMBTs, 58% originated from the pelvis and 42% were from the proximal femur. Twenty patients had chondrosarcomas (61%), 10 had osteosarcomas (30%), and 3 had sarcomas of another histological subtype (9%).

Results

The mean follow-up was of 76 months (range: 24–220 months). The cumulative probabilities of revision for any reason were 52% (95% confidence interval [CI] 30–70%) 5 years after surgery. The 5-year cumulative probabilities of revision were 13% (95% CI 4–27%), 24% (95% CI 10–42%), and 34% (95% CI 14–56%) for mechanical, infectious, and tumoral reasons, respectively. The 5-year cumulative probabilities of revision for any reason were 78% (95% CI 37–94%) and 14% (95% CI 2–38%) for the pelvis and proximal femur, respectively (p = 0.004). Posterior column preservation was significantly associated with more mechanical complications even after adjusting for the resection site (p = 0.043).

Conclusion

Half of patients undergoing EAR of the hip joint for PMBT of the proximal femur or acetabulum will require another operation. EAR of the pelvis is associated with significantly worse outcome than EAR of the proximal femur.

Extra-articular resection of the hip joint for pelvic sarcomas: Are there any oncological and functional risks compared with intra-articular resection?

BACKGROUND

While extra-articular resection (EAR) of the knee and shoulder joint is associated with poorer clinical outcomes, the oncological and functional risks of EAR of the hip joint are unknown. We aimed to compare these risks between EAR of the hip joint and intra-articular resection (IAR).

METHODS

We conducted a comparative study of 75 patients who underwent en-bloc tumour resection and limb-salvage reconstruction for bone sarcomas of the peri-acetabulum between 1996 and 2016. We divided patients into two groups for analyses; EAR (n = 21) and IAR (n = 54).

RESULTS

There was no statistical difference in oncological outcomes; the 5-year cumulative incidence of disease-specific death was 34% and 35% in the EAR and IAR groups, respectively (p = 0.943), and the 5-year cumulative incidence of LR was 26% and 34%, respectively (p = 0.482). The most common complications were dislocation (28%) and deep infection (28%); there was equally no difference between the groups. The mean Musculoskeletal Tumour Society score was 66% and 65% in the EAR and IAR groups, respectively (p = 0.795), and were significantly lower in patients with deep infection (52% vs. 69%; p = 0.013). In a sub-analysis on the outcomes in patients who underwent PI-uninvolved PII-resection for chondrosarcoma, no major differences in oncologic and functional outcomes were confirmed.

CONCLUSION

Patients undergoing EAR and limb-salvage reconstructions of the hip joint have undistinguishable oncological, clinical and functional outcomes compared to those undergoing IAR and reconstructions. If preoperative imaging suggests articular tumour involvement, there appears to be no detrimental effect of undertaking EAR to optimise local control.

Proximal femur sarcomas with intra-articular disease-Do intra-articular resections provide adequate local control?

BACKGROUND AND OBJECTIVES

Hip preserving (intra-articular) resections for proximal femur sarcoma have better function compared to peri-acetabular (extra-articular) resections, which are more complex and morbid. But, do intra-articular resections in selected cases with intra-articular disease provide adequate local control?

METHOD

Extra-articular resection or intra-articular resection in cases without pathologic fracture or away from joint/capsule was classified as a planned safe margin (SM). Circumferential removal of labrum without acetabular resection in cases without gross joint contamination was classified as planned close margins (CM). We analyzed local recurrence-free survival (LRFS) (death as a competing event) for 86 proximal femur resections (SM = 55, CM = 31).

RESULTS

The 5 years LRFS was 84% (n = 6/55, 10%) in the SM group and 67% (n = 4/31, 12%) in the CM group. There was no worsening of local recurrence (LR) in the CM group (subdistribution hazard [sH] = 0.69; 95% confidence interval [CI], 0.21-2.29; P = .56). Poor chemotherapy-induced necrosis predicted worse LR (sH = 0.1; 95% CI, 0.01-0.8; P = .03). Overall survival was 16% (SE 8%) at 5 years with LR vs 64% (SE 7%) without LR (P = .0076).

CONCLUSION

In proximal femur sarcomas with potential for involvement of the hip joint, a CM in selected cases did not worsen LR; providing an option for avoiding additional morbidity with extra-articular resections.

Extra-Articular Hip Resection and Reconstruction with Custom Acetabular Resection Guide and Implants in a Case of High-Grade Spindle Cell Sarcoma of the Proximal Femur: A Case Report

CASE

A 29-year-old man was admitted with acute atraumatic left hip pain and inability to bear weight. Subsequent workup revealed an intracapsular pathologic fracture of the femoral neck secondary to a high-grade spindle cell sarcoma. A unique method of extra-articular resection and reconstruction using a 3-dimensional (3D)-printed custom cutting jig and a custom acetabular component was pursued. Wide margins were achieved without violating the joint capsule but preserving pelvic integrity, allowing a return to an active lifestyle.

CONCLUSION

Three-dimensional-printed custom resection guides and implants can help achieve adequate resection margins while preserving pelvic integrity and function.

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.

Advances in tumour endoprostheses: a systematic review

Tumour endoprostheses have facilitated limb-salvage procedures in primary bone and soft tissue sarcomas, and are increasingly being used in symptomatic metastases of the long bones.

The objective of the present review was to analyse articles published over the last three years on tumour endoprostheses and to summarize current knowledge on this topic. The NCBI PubMed webpage was used to identify original articles published between January 2015 and April 2018 in journals with an impact factor in the top 25.9% of the respective category (orthopaedics, multidisciplinary sciences).

The following search-terms were used: tumour endoprosthesis, advances tumour endoprosthesis, tumour megaprosthesis, prosthetic reconstruction AND tumour. We identified 347 original articles, of which 53 complied with the abovementioned criteria.

Articles were categorized into (1) tumour endoprostheses in the shoulder girdle, (2) tumour endoprostheses in the proximal femur, (3) tumour endoprostheses of the knee region, (4) tumour endoprostheses in the pelvis, (5) (expandable) prostheses in children and (6) long-term results of tumour endoprostheses.

The topics of interest covered by the selected studies largely matched with the main research questions stated at a consensus meeting, with survival outcome of orthopaedic implants being the most commonly raised research question.

As many studies reported on the risk of deep infections, research in the future should also focus on potential preventive methods in endoprosthetic tumour reconstruction.

Cite this article: EFORT Open Rev 2019;4:445-459. DOI: 10.1302/2058-5241.4.180081