The survivorship of protrusio cages for metastatic disease involving the acetabulum

A Prospective Study of the IlluminOss Photodynamic Nail System for Pelvic Stabilization: Treatment of Impending and Actual Fractures from Metastatic Bone Disease, Multiple Myeloma, and Primary Bone Lymphoma

Background

The stabilization of metastatic lesions in the periacetabular region can be successfully performed using percutaneous techniques. Photodynamic nails (PDNs) are among the available tools for stabilization. Data on postoperative complications and functional outcomes are, however, scarce.

Methods

Patients undergoing percutaneous stabilization using PDNs (IlluminOss Medical) for impending or actual minimally displaced pathological fractures of the pelvis from metastatic bone disease, multiple myeloma, or primary bone lymphoma were enrolled prospectively. Outcomes were assessed preoperatively and postoperatively at the 2-day, 2-week, 6-week, 3-month, 6-month, and 1-year time points. Functional outcomes assessed included the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, PROMIS Pain Interference, Combined Pain and Ambulatory Function (CPAF), EuroQol-Visual Analogue Scale (EQ-VAS), and Musculoskeletal Tumor Society (MSTS) scores. Pain was assessed using a VAS.

Results

A total of 30 patients treated with PDNs were included. The median VAS pain score dropped from 60 points preoperatively to 30 at 6 weeks postoperatively (p = 0.004). The median CPAF score improved from 6 preoperatively to 7 postoperatively at the 6-week mark. The median EQ-VAS score showed significant improvement at 6 weeks (70 versus 50; p = 0.006). The median 2-week PROMIS Pain Interference score was significantly lower than preoperatively (64.1 versus 66.9; p = 0.03). An improvement in the median PROMIS Physical Function score was seen at 6 weeks following surgery compared with preoperatively (37 versus 30.1; p = 0.001). A significant improvement in the MSTS score was seen as soon as 2 days after surgery (77% versus 40%; p < 0.0001).

Conclusions

Among patients with pelvic bone metastases, multiple myeloma, or primary bone lymphoma, we found that treatment using PDNs resulted in immediate return to ambulation and rapid functional outcome improvement, with low complication rates. In this population, this technique represents a safe alternative to open surgery.

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.

Clinical efficacy analysis of percutaneous "tripod" combined with radiofrequency ablation and bone cement filling in the treatment of periacetabular metastases

BACKGROUND

To investigate the clinical efficacy of a percutaneous "tripod" combined with radiofrequency ablation and bone cement filling surgery in treating acetabular bone metastases.

METHODS

We retrospectively analyzed 11 patients who underwent percutaneous "tripod" combined with radiofrequency ablation and bone cement filling for acetabular bone metastases at a tertiary care hospital from February 2021 to December 2022.

RESULTS

11 cases with 13 hips underwent this procedure, including two female patients who underwent both sides, and the rest were unilateral. All cases were followed up for 3-24 months, with a mean of 12 months and a median follow-up time of 11 months. Two of the 11 patients died by the final follow-up, and nine survived. One died 7 months after surgery, and one died 8 months after surgery; the survival of the deceased patients was 7.5 months (range: 7-8 months), with a median survival time of 7.5 months. All 11 patients completed the surgery successfully, and the average unilateral operation time was 167.4 min (148-193). The amelioration of postoperative pain, concomitant with improved quality of life, was observed significantly, ultimately resulting in a prolonged and sustained effect.

CONCLUSIONS

The combination of percutaneous "tripod", radiofrequency ablation, and bone cement filling can effectively relieve pain without delaying the patient's systemic anti-tumor therapy and is a minimally invasive, safe, and effective procedure for the treatment of periacetabular metastases.

Minimally invasive management of pathologic fractures of the pelvis and sacrum: Tumor ablation and fracture stabilization

BACKGROUND

Pathologic fractures of the pelvis/sacrum due to metastatic bone disease (MBD) cause pain and dysfunction due to mechanical instability of the pelvic ring. This study presents our multi-institutional experience with percutaneous stabilization of pathologic fractures and osteolytic lesions from MBD throughout the pelvic ring.

METHODS

The records of patients undergoing this procedure from 2018 to 2022 were reviewed retrospectively from two institutions. Surgical data and functional outcomes were recorded.

RESULTS

Fifty-six patients underwent percutaneous stabilization, with a median operative duration of 119 min (interquartile range [IQR]: 92.8, 167) and median estimated blood loss of 50 mL (IQR: 20, 100). The median length of stay was 3 days (IQR: 1, 6), and 69.6% (n = 39) of patients were discharged home. Early complications included one partial lumbosacral plexus injury, three acute kidney injuries, and one case of intra-articular cement extravasation. Late complications included two infections and one revision stabilization procedure for hardware failure. Mean Eastern Cooperative Oncology Group (ECOG) scores improved from 3.02 (SD 0.8) preoperatively to 1.86 (SD 1.1) postoperatively (p < 0.001). Ambulatory status also improved (p < 0.001).

CONCLUSIONS

Percutaneous stabilization of pathologic fractures and osteolytic defects of the pelvis and sacrum is a procedure that improves patient function, ambulatory status and is associated with a limited complication profile.

Operative management of metastatic disease of the acetabulum: review of the literature and prevailing concepts

Metastatic disease of the periacetabular region is a common problem in orthopaedic oncology, associated with severe pain, decreased mobility, and substantial decline of the quality of life. Conservative management includes optimisation of pain management, activity modification, and radiation therapy. However, patients with destructive lesions affecting the weight-bearing portion of the acetabulum often require reconstructive surgery to decrease pain and restore mobility. The goal of surgery is to provide an immediately stable and durable construct, allowing immediate postoperative weight-bearing and maintaining functional independence for the remaining lifetime of the patient. A variety of surgical techniques have been reported, most of which are based upon cemented total hip arthroplasty, but also include porous tantalum implants and percutaneous cementoplasty. This review discusses the various reconstructive concepts and options, including their respective indications and outcome. A reconstructive algorithm incorporating different techniques and strategies based upon location and quality of remaining bone is also presented.

Functional and Survival Outcomes of Patients following the Harrington Procedure for Complex Acetabular Metastatic Lesions

Background: The Harrington surgical technique makes it possible to manage complex, extensive bone lesions using pins and cement to consolidate bone for acetabular cup positioning. However, it may be associated with a high reoperation rate, and the functional results of this surgery are not precisely described in the literature. Methods: In a monocentric retrospective study including all patients operated on using the Harrington procedure associated with THA between 2005 and 2020, we aimed to assess preoperative and postoperative function, reoperation-free survival, and overall survival. Results: Functional improvement was significant for Parker scores (preoperative: 3.6 ± 2.0; 6-month follow-up: 6.6 ± 3.2; 12-month follow-up: 7.6 ± 2.1) and Musculoskeletal Tumor Society (MSTS) scores (preoperative: 31.1 ± 16.2%; 6-month follow-up: 67.7 ± 30.6%; 12-month follow-up: 82.4 ± 24.0%). Of the 21 patients included, the reoperation-free survival rate was 76.1% [CI 95%: 58.1–99.7] at six and twelve months, with the main complications being pin migration (50.0%) and infection (25%). The patient overall survival rate was 76.2% [95% CI: 59.9–96.7] at six months and 61.9% [95% CI: 59.9–96.7] at 12 months. Discussion: These results underlined significant functional improvements following a conventional Harrington procedure, with acceptable reoperation rates.

Skeletal metastatic disease of the acetabulum: historical and evolving techniques for management

The skeleton is the third most common organ system to be involved in the spread of metastatic carcinomas. More options for systemic therapies, surgeries and adjuvant treatments are providing longer survival for patients with known metastatic carcinoma to the bone. This means more patients are living with metastatic skeletal disease than ever before. If metastatic disease results in enough bone loss it can cause significant pain and dysfunction for patients. The acetabulum and pelvis are common sites of metastatic disease. The complex anatomy of the bony pelvis and acetabulum, as well as its proximity to important neurovascular and pelvic structures, can make surgical management of acetabular metastatic disease technically difficult. Decision making for patients with symptomatic skeletal metastatic disease is complex, and multidisciplinary teams can be helpful in providing appropriate care for these patients. Systemic chemotherapies, immunotherapies or targeted therapies may not adequately treat large areas of metastatic disease in the hip and pelvis. Radiation therapy is not successful for all patients. Fortunately, there are evolving therapies that are giving patients and providers more options for treatment. This review article will cover some of those new therapies and their outcomes, focusing on newer ablative, minimally invasive and surgical reconstruction techniques for metastatic disease involving the acetabulum. Decision making in the management of a patient's metastatic acetabular disease is still made on a case by case basis. This review article hopefully will remind clinicians of the variety of treatments available to these patients.

The use of a non-biological, bridging, antiprotrusio cage in complex revision hip arthroplasty and periacetabular reconstructive oncologic surgery. Is still today a valid option?: A mid/long-term survival and complications' analysis

INTRODUCTION

Burch-Schneider-like antiprotrusio cages (B-SlAC) still remain helpful implants to bridge severe periacetabular bone losses. The purpose of this study was to evaluate outcomes and estimate both cages' failures and complication risks in a series of B-SlAC implanted in revision of failed total hip arthroplasties (THA) or after resection of periacetabular primary or secondary bone malignancies. Risk factors enhancing the chance of dislocations and infections were checked.

MATERIALS AND METHODS

We evaluated 73 patients who received a B-SlAC from January 2008 to January 2018. Group A, 40 oncological cases (22 primary tumors; 18 metastases); Group B, 33 failed THAs. We compared both Kaplan-Meier estimates of risk of failure and complication with the cumulative incidence function, taking account the competing risk of death. Cox proportional hazards model was utilized to identify possible predictors of instability and infection. Harris hip score HHS was used to record clinical outcomes.

RESULTS

Medium follow-up was 80 months (24-137). Average final HHS was 61 (28-92), with no differences within the two groups (p > 0.05). The probabilities of failure and complications were 57% and 26%, respectively, lower in the oncologic group than in the rTHA group (p =0 .176; risk 0.43) (p = 0.52; risk 0.74). Extended ileo-femoral approach and proximal femur replacement (p =0.02, risk ratio = 3.2; p = 0.04, rr = 2.1) were two significant independent predictors for dislocations, while belonging to group B (p = 0.04, rr = 2.6) was predictable for infections.

CONCLUSION

Burch-Schneider-like antiprotrusio cages are a classical non-biological acetabular reconstruction method that surgeons should bear in mind when facing gross periacetabular bone losses, independently of their cause. However, dislocation and infection rates are high. Whenever possible, we suggest preserving the proximal femur in revision THA, and to use a less-invasive postero-lateral approach to reduce dislocation rates in non-oncologic cases.

Reinforced reconstruction: A technique for the treatment of periacetabular metastases

Purpose

To describe a single-stage reconstruction of intraarticular periacetabular metastases that utilizes a cemented acetabular liner reinforced with percutaneous screws oriented along various osseous fixation pathways.

Methods

A retrospective evaluation of all patients with intraarticular periacetabular metastases who underwent the procedure outlined.

Results

16 procedures (1 bilateral) were included. There were no intraoperative complications or postoperative mechanical failures to date despite allowing the patients to immediately weight bear in the postoperative setting.

Discussion

Utilizing osseous fixation pathways to reinforce a cemented acetabular cup represents a safe and effective strategy to allow for immediate weightbearing in patients with periacetabular metastases.

A graphic guide to the percutaneous tripod acetabular reconstruction for metastatic cancer

Symptomatic peri-acetabular metastatic lesions are often treated with open surgery such as modified Harrington procedures. In an effort to avoid surgical complications inherently associated with open surgical approaches, we developed and recently reported a novel Tripod percutaneous screw technique. The tripod technique is minimally invasive and was found to yield excellent outcomes regarding both pain control and functionality. The procedure is performed in a standard operative theater using fluoroscopic guided percutaneous screws. Despite the simplicity of intraoperative set-up and instrumentation, it is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging for even an experienced orthopedic surgeon. The technique and bony conduits were previously described in the trauma literature, however, there are key points of difference in the setting of metastatic disease. Here we provide a compilation of a stepwise graphic guide for the tripod model in the setting of metastatic peri-acetabular lesions, as well as the tips and tricks based on our own experience. These encompass preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, postoperative care, and subsequent conversion to a cemented total hip arthroplasty, if needed.

Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases

INTRODUCTION

The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival.

HYPOTHESIS

The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies.

METHODS

Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)].

RESULTS

Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer.

CONCLUSION

Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

A Novel Tripod Percutaneous Reconstruction Technique in Periacetabular Lesions Caused by Metastatic Cancer

BACKGROUND

Metastatic lesions in the periacetabular region can cause pain and immobility. Symptomatic patients are often treated surgically with a total hip replacement using various modified Harrington methods. These open surgical procedures confer inherent risks. Prolonged recovery and potential complications may delay adjuvant radiation and systemic therapy.

METHODS

We describe a novel technique for acetabular reconstruction. Three large-bore cannulated screws are placed percutaneously under fluoroscopy in a tripod configuration to reinforce the mechanical axes of the acetabulum. Increased stability improves pain control and permits weight-bearing.

RESULTS

Twenty consecutive patients with periacetabular metastases were treated using the tripod technique. Eighteen patients (90%) had Harrington class-III lesions, and 2 patients had Harrington class-II lesions. The mean surgical time was 2.3 hours. Sixteen patients (80%) were able to get out of bed on postoperative day 1. At 3 months postoperatively, there was significant improvement in pain as documented on their visual analog scale (p < 0.01) and in functionality as measured by the Eastern Cooperative Oncology Group score (p < 0.01). The mean follow-up time was 7 months (range, 0.6 to 20 months). At the most recent follow-up, only 3 among the 16 surviving patients were using opioids chronically for pain. Total hip arthroplasty was performed in 4 patients (20%) in a staged fashion using the previously placed screws as support for a cemented cup and obviating the need for a cage device. Of the 16 patients, 15 could walk either independently (6 patients) or using an ambulatory aid (9 patients). Eight patients with the primary tripod reconstruction survived >6 months postoperatively. They were found to have either new bone formation filling the defects or healing of the pathological fractures. There has been no implant loosening or failure.

CONCLUSIONS

The tripod technique is a novel application to provide safe and effective pain relief in the context of periacetabular metastatic disease. It can be easily converted to support a cemented acetabular cup for a total hip replacement should disease progression occur. This technique provides an alternative to open surgery as currently practiced in these patients.

LEVEL OF EVIDENCE

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

Is an Acetabular Cage and Cement Fixation Sufficiently Durable for the Treatment of Destructive Acetabular Metastases?

BACKGROUND

Destructive bony acetabular metastases cause pain, pathological fractures, and loss of mobility. Although multiple fixation options are available, we have favored a rigid stainless steel partial pelvic cage for acetabular fixation in these patients; however, little is known about the durability of this approach. QUESTION/PURPOSES: (1) How common was loss of fixation in a small series of metastatic acetabular defects treated with an acetabular cage and cemented total hip replacement? (2) What is the implant survival free from reoperation or revision at 2 and 4 years using a competing-risks survivorship estimator in patients thus treated? (3) What complications were associated with the treatment? (4) What level of postoperative mobility was achieved?

METHODS

Between 2006 and 2017, we treated all acetabular metastases that needed surgical intervention, not amenable to conventional cemented THA alone with our single technique of acetabular partial pelvic cage and cemented total hip replacement. We treated 47 hips in 46 patients whose acetabular metastasis led to acetabular collapse or who were unresponsive to nonoperative measures of radiation therapy and analgesia. Routine followup occurred at 3 and 12 months; 17 of 46 patients (37%) died before 1 year, and all other patients were followed beyond 1 year. Only one patient who remains alive has not been seen in the past 5 years. Loss of fixation was determined by radiological or clinical signs of cage loosening. Survivorship free from reoperation or revision at 2 and 4 years was determined using competing-risks analysis. We did not assess patient-reported outcomes, but we did have data on the proportion of patients who were able to ambulate in the community and if so, what assistive devices they used, which we obtained by chart review.

RESULTS

One patient experienced cage loosening identified 8 years postoperatively as a result of local disease progression and has been managed with observation. No patients underwent revision for loss of acetabular fixation. The cumulative incidence of reoperation or revision was 8% at 2 years (95% CI, 3.6-12.6) and 16% at 4 years (95% CI, 9.2-23.2). Four patients had postoperative dislocations, of which three underwent reoperation. One patient developed a postoperative deep infection and underwent reoperation. One patient died within 30 days of surgery. Only one patient did not ambulate in the community postoperatively; 23 ambulated independently, 10 with the use of a walking stick and 12 using a walker.

CONCLUSIONS

In this small series, we found this approach sufficiently durable to continue its use for patients with acetabular metastases with collapse or those not responding to nonoperative measures. However, comparison studies are needed to determine whether it is superior or inferior to other available alternatives.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Rapid return to function and stability with dual mobility components cemented into an acetabular reconstructive cage for large osseous defects in the setting of periacetabular metastatic disease

BACKGROUND AND OBJECTIVES

Large acetabular defects secondary to metastatic disease frequently require extensive acetabular reconstruction. Techniques of acetabular reconstruction have been described, but no consensus for the management of these defects has been reached so far. We present our technique and patient outcomes for acetabular reconstruction by cementing a dual mobility cup into an acetabular cage.

METHODS

We reviewed 152 total hip arthroplasties and identified 19 patients with periacetabular metastatic disease and large defects who required acetabular reconstruction utilizing a dual mobility cup cemented into an acetabular reconstructive cage. The following outcomes were evaluated: pain relief, functional improvement, postoperative complications.

RESULTS

Mean follow-up was 3 years, with 13 of the 19 patients eligible for 2-year follow-up. Patients reported a significant improvement in both pain and functional outcomes. There were no dislocations or signs of loosening. Two patients developed postoperative infections. One patient required hemipelvectomy 16 months postop due to recurrence of metastatic disease.

CONCLUSIONS

Cementing a dual mobility cup into an acetabular cage provides a highly stable and durable option for patients with periacetabular metastatic disease and large defects. Patients are able to return to immediate full weight bearing with significant improvement in both function and pain at 2 years.

Total Hip Arthroplasty for Periacetabular Metastatic Disease. An Original Technique of Reconstruction According to the Harrington Classification

BACKGROUND

Periacetabular metastatic disease requires complex acetabular reconstruction. The complication rate for these frail patients is high. Various cement-rebar reinforced techniques allowing cemented total hip arthroplasty (THA) have been described. The optimal procedure has not yet been identified.

METHODS

A continuous series of 131 THAs performed in 126 patients with periacetabular metastatic disease was prospectively included in this study. After bone metastasis curettage and cementation, an original technique of acetabular reconstruction was performed using a dual mobility cup cemented into an acetabular reinforcement device (ie, Kerboull cross-plate or Burch-Schneider antiprotrusio cage) according to the Harrington classification. Functional outcome for independent ambulation in the community, pain relief, and occurrence of dislocation or mechanical failure of the acetabular reconstruction were assessed.

RESULTS

At a mean follow-up of 33 ± 17 months, the improvement in the preoperative to postoperative functional outcome and pain relief was significant (P < .001). The dislocation rate was 2%. Two of the 3 cases of dislocation occurred in acetabular reconstructions associated with a proximal femoral arthroplasty. No mechanical failure or aseptic loosening of the acetabular reconstruction was observed.

CONCLUSION

This study emphasized that our original technique combining bone metastasis curettage and cementation, acetabular reinforcement device and cemented dual mobility cup was effective to restore a painless functional independence and ensure a durable acetabular reconstruction able to face to adjuvant radiation therapy and mechanical solicitations for long survivors. In addition, dual mobility cup limited the risk of dislocation in patients undergoing THA for periacetabular metastatic disease.

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.

Early Results of Acetabular Reconstruction After Wide Periacetabular Oncologic Resection

BACKGROUND

Reliable acetabular fixation in total hip arthroplasty following periacetabular resections is challenging. Tantalum components have been successfully implemented for difficult revision arthroplasties, but, to our knowledge, have not been reported for acetabular reconstruction following oncologic periacetabular resection. The primary purpose of the current study was to determine the early clinical outcomes, complications, and radiographic findings for acetabular reconstruction after oncologic periacetabular resection. In addition, a novel classification scheme for primary periacetabular resections and reconstructions is presented.

METHODS

We reviewed 10 consecutive patients treated with tantalum acetabular reconstruction following periacetabular resection. All patients had a primary acetabular malignancy including chondrosarcoma (n = 7) and osteosarcoma (n = 3). The cohort included 6 males (60%). The mean age was 54 years (range, 30 to 73 years). The mean follow-up was 59 months (range, 8 to 113 months).

RESULTS

At the most recent follow-up, 9 patients were alive and 1 had died of the respective disease. All patients obtained full ambulatory status with the use of gait aids. Postoperative complications included dislocation (n = 3), wound-healing disturbance (n = 1), and deep venous thrombosis (n = 1). Two patients underwent reoperations for recurrent dislocations. The mean postoperative Harris hip score was 75 points (range, 49 to 92 points).

CONCLUSIONS

Preliminary results of tantalum reconstruction following periacetabular resections provide reasonable improvement in early clinical outcomes and stable fixation in situations with massive bone loss and compromised bone quality. As expected due to the lack of a functioning abductor mechanism from the wide oncologic resection, early dislocations remain a concern. As such, we now consider the primary use of increasing constraint, but it must be balanced with the often compromised host bone.

LEVEL OF EVIDENCE

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

Reconstruction of metastatic acetabular defects using a modified Harrington procedure

BACKGROUND AND PURPOSE

Metastases engaging the acetabulum result in significant disability. We investigated the outcome after curettage and reconstruction of the defect with a protrusio cage, retrograde screws, and a cemented total hip arthroplasty.

PATIENTS AND METHODS

We retrospectively identified 70 consecutive patients who were surgically treated for metastatic disease of the acetabulum between 1995 and 2012 using the above technique. The type of primary tumor, extent of the disease, degree of acetabular erosion, and type of implant used were identified. Patient and implant survival, complications, and functional outcome were recorded.

RESULTS

There were no mortalities in the perioperative period (30 days after surgery). Median overall patient survival was 12 months. Prosthesis survival was 92% at 1 year and 89% at 5 years. One third of the patients suffered a complication, the most frequent one being dislocation. The functional outcome was good. Multiple skeletal or visceral metastases and specific types of cancer were associated with poor patient survival.

INTERPRETATION

Reconstruction of metastatic acetabular defects using a protrusio cage stabilized with retrograde screws and a cemented total hip arthroplasty is a safe procedure that provides efficient relief of symptoms. Patients with extensive disease, especially when diagnosed with specific types of cancer, have a very poor prognosis. The complication rate is substantial, the most frequent being dislocation. However, revision surgery is seldom required and prosthesis survival is high.

Functional outcome and complications following reconstruction for Harrington class II and III periacetabular metastasis

BACKGROUND

Metastatic bone disease involving the acetabulum is a debilitating condition causing significant pain and disability for patients. Many methods of reconstruction have been described for treating Harrington class II and III lesions with different results and complications. Our objectives were to report functional results, implant survival and complications following reconstruction for Harrington class II and III periacetabular metastases by using anti-protusio cages, screws and joint replacement.

METHODS

We reviewed 22 patients undergoing acetabular reconstruction for metastatic disease. There were 5 Harrington class II and 17 class III lesions. Intralesional curettage, multiple screws and cemented total hip replacement were performed in all patients. Anti-protusio cages were used in 19 hips. No Steinmann pins were used. Sixteen patients died at a median survival time of 12 months (range, 4 to 28 months) after surgery. Six patients were alive at last follow-up at a median of 8 months (range, 3 to 15 months).

RESULTS

Postoperatively, the average ECOG score was improved from 3.1 to 1.7 and Visual Analog Scale was improved from 8.4 to 2.2. One patient developed hip dislocation and one patient developed superficial infection. The mean Musculoskeletal Tumor Society (MSTS) functional score was 70 (range, 27 to 87). There was no prosthetic loosening or revision. Twenty patients were able to walk. Eight patients became community ambulators, twelve became household ambulators and two were bed-bound.

CONCLUSIONS

Good functional outcome and better ambulation could be expected following class II and III periacetabular reconstruction using anti-protusio cages, screws and cemented hip replacement. Few complications were noted and manageable. Although most of these patients with metastatic disease had limited life expectancies, their quality of life would be improved with appropriate patient selection and surgical reconstruction.

The outcome of surgical treatment for peri-acetabular metastases

We reviewed the outcome of patients who had been treated operatively for symptomatic peri-acetabular metastases and present an algorithm to guide treatment. The records of 81 patients who had been treated operatively for symptomatic peri-acetabular metastases between 1987 and 2010 were identified. There were 27 men and 54 women with a mean age of 61 years (15 to 87). The diagnosis, size of lesion, degree of pelvic continuity, type of reconstruction, World Health Organization performance status, survival time, pain, mobility and complications including implant failure were recorded in each case. The overall patient survivorship at five years was 5%. The longest lived patient survived 16 years from the date of diagnosis. The mean survival was 23 months (< 1 to 16 years) and the median was 15 months. At follow-up 14 patients remained alive. Two cementoplasties failed because of local disease progression. Three Harrington rods broke: one patient needed a subsequent Girdlestone procedure. One 'ice-cream cone' prosthesis dislocated and was subsequently revised without further problems. We recommend the 'ice-cream cone' for pelvic discontinuity and Harrington rod reconstruction for severe bone loss. Smaller defects can be safely managed using standard revision hip techniques.

Management of metastatic bone disease of the acetabulum

Metastatic acetabular disease can be severely painful and may result in loss of mobility. Initial management may consist of diphosphonates, narcotic analgesics, radiation therapy, protected weight bearing, cementoplasty, and radiofrequency ablation. Patients with disease affecting large weight-bearing regions of the acetabulum and with impending failure of the hip joint are unlikely to gain much relief from nonsurgical treatment and interventional procedures. The profound osteopenia of the acetabulum, limited healing potential of the fracture, and projected patient life span and function necessitate surgical techniques that provide immediate stable fixation to reduce pain and restore ambulatory function. Current reconstructive procedures, including cemented total hip arthroplasty, the saddle or periacetabular endoprosthesis, and porous tantalum implants, are based on the quality of remaining acetabular bone as well as the patient's level of function and general health. Well-executed acetabular reconstructions can provide durable hip joints with good pain relief and function.

The Burch-Schneider cage for reconstruction after metastatic destruction of the acetabulum: outcome and complications

INTRODUCTION

The Burch-Schneider cage is an established implant in revision surgery after hip arthroplasty that is used for reconstructing osseous defects in the acetabulum. However, there are only a few reports about the use of cages in patients with metastatic destruction of the acetabulum. The aim of this retrospective study was to assess the outcome and complications of this procedure.

METHODS

The records of 15 patients with metastatic acetabular defects using the Burch-Schneider cage were examined pre- and postoperatively. X-rays were analyzed, clinical and functional outcome was assessed by the Harris hip score (HHS) and the visual analogue scale (VAS) for subjective pain perception. The follow-up of 14 months was due to the underlying disease.

RESULTS

The overall revision rate was 26%. The HHS improved from 33 (range 25-39) to 69 (range 35-93). The VAS improved from 7.5 to 3.2.

CONCLUSION

The life expectancy of patients with bone metastasis can be short and patients should be carefully selected for a surgical treatment. The implantation of a protrusio cage can improve the quality of life in these patients by increasing their mobility and reducing pain. The complication rate is comparable with the rates for other surgical methods for metastatic acetabular lesions. For surgeons who are familiar with this implant, it seems to be a good option in treating such cases.

Reconstruction with modular hemipelvic prosthesis for the resection of solitary periacetabular metastasis

BACKGROUND

The outcomes of patients with solitary metastasis around the acetabulum who received en bloc resection and reconstruction are unclear. The purpose is to evaluate the oncologic results, complications, and functional outcomes in these patients.

METHODS

Fifteen patients who underwent periacetabular resection and modular endoprosthetic reconstruction were reviewed retrospectively.

RESULTS

Eleven patients were alive and four had died of their respective diseases. The mean follow-up time for the living patients and the non-surviving patients was 32 and 11 months, respectively. One of the three patients presented with local recurrence received hindquarter amputation. Five patients with superficial wound problem were treated with debridement and were healed eventually. Two patients who had hip dislocation received closed reduction. Pain was relieved in most patients, and ten patients were able to walk outside their house. The average MSTS 93 score was 20.9 of a total of 30 points (69.7%). When evaluated according to the modified Allan scoring system, postoperative scores on pain, independence, and mobility had significant improvement.

CONCLUSION

En bloc tumor resection and reconstruction with modular hemipelvic prosthesis in patients who had a solitary periacetabular metastasis can provide long-term survive, tumor local control, low complication rate, and good functional recovery.