Internal hemipelvectomy

Changes in psoas muscle size and ambulatory function after internal hemipelvectomy without reconstruction

Internal hemipelvectomy without reconstruction of the pelvis is a viable treatment for pelvic sarcoma; however, the time it takes to return to excellent function is quite variable. Some patients require greater time and rehabilitation than others. To determine if psoas muscle recovery is associated with changes in ambulatory function, we retrospectively evaluated psoas muscle size and limb-length discrepancy (LLD) before and after treatment and their correlation with objective functional outcomes. T1-weighted MR images were evaluated at three intervals for 12 pelvic sarcoma patients following interval hemipelvectomy without reconstruction. Correlations between the measured changes and improvements in Timed Up and Go test (TUG) and gait speed outcomes were assessed both independently and using a stepwise multivariate regression model. Increased ipsilesional psoas muscle size from three months postoperatively to latest follow-up was positively correlated with gait speed improvement (r = 0.66). LLD at three months postoperatively was negatively correlated with both TUG (r = -0.71) and gait speed (r = -0.61). This study suggests that psoas muscle strengthening and minimizing initial LLD will achieve the greatest improvements in ambulatory function. LLD and change in hip musculature remain substantial prognostic factors for achieving the best clinical outcomes after internal hemipelvectomy. Changes in psoas size were correlated with the amount of functional improvement. Several patients in this study did not return to their preoperative ipsilateral psoas size, indicating that monitoring changes in psoas size could be a beneficial rehabilitation strategy.

Cranial internal hemipelvectomy (iliectomy) with limb sparing for a dog with ilial chondrosarcoma: A case report

Cranial internal hemipelvectomy can be successful for excision of ilial CSA with minimal complications. Iliectomy with adjuvant radiation therapy was well tolerated in a dog with grade II ilial CSA. The dog survived 1,271 days postoperatively and supposedly succumbed to a disease process unrelated to the CSA.

Ischiectomy With Limb Preservation for a Dog With Ischial Chondrosarcoma: Case Report and Surgical Technique

OBJECTIVE

To describe the surgical technique for ischiectomy in the dog and to report the procedure in a case.

STUDY DESIGN

Case report.

ANIMAL

An 11-year-old spayed female mixed breed dog with chondrosarcoma of the ischium.

METHODS

The dog presented for hindlimb lameness and evaluation after a radiographic finding of a lytic lesion confined to the left ischium. Following staging and confirmation of stage 1 disease, an ischiectomy with preservation of the hindlimb was performed.

RESULTS

The dog recovered from surgery and was initially moderately lame on the hindlimb. Over time, the dog regained satisfactory hindlimb use and was alive >500 days postoperative with no evidence of local recurrence or metastatic disease.

CONCLUSIONS

Ischiectomy with hindlimb preservation is a technically straight-forward procedure and in this case, resulted in good hindlimb function postoperatively. The procedure should be considered for the treatment of dogs with bone tumors confined to the ischium.

Internal hemipelvectomy in the management of pelvic Ewing sarcoma - are outcomes better than with radiation therapy?

BACKGROUND

Pelvic Ewing sarcoma (ES) is commonly associated with a worse prognosis. Large size and location limit local control options to radiation therapy, and local recurrences are common. We evaluated the impact of hemipelvectomy and radiation on outcomes, including function.

MATERIALS AND METHODS

Thirty-nine patients (median age 13.5years) with ES of the pelvis and sacral bones were treated during the period 2000-2012. Fifteen were treated with definitive radiotherapy (RT), 9 patients underwent hemipelvectomy alone, and 15 were treated with combined hemipelvectomy and RT.

RESULTS

Twenty patients (51.2%) are alive with a median follow-up 3.2years from diagnosis. Median time from diagnosis to relapse was 1.3years. Three-year estimates of EFS and OS were 47% and 61%, respectively. Patients treated with surgery or surgery with RT had better outcome than patients treated with RT only (3-year OS 78% or 81% vs. 36%, respectively, p=0.00083). The outcome of patients with pelvic ES treated with hemipelvectomy was not significantly different from the outcome of all patients with Ewing sarcoma treated on the national Polish protocol.

CONCLUSIONS

Internal hemipelvectomy offers good chances of cure for patients with pelvic ES, with a reasonable rate of complications and good function.

En bloc hemisacrectomy and internal hemipelvectomy via the posterior approach

OBJECT

Traditionally, hemisacrectomy and internal hemipelvectomy procedures have required both an anterior and a posterior approach. A posterior-only approach has the potential to complete an en bloc tumor resection and spinopelvic reconstruction while reducing surgical morbidity.

METHODS

The authors describe 3 cases in which en bloc resection of the hemisacrum and ilium and subsequent lumbopelvic and pelvic ring reconstruction were performed from a posterior-only approach. Two more traditional anterior and posterior staged procedures are also included for comparison.

RESULTS

In all 3 cases, an oncologically appropriate surgery and spinopelvic reconstruction were performed through a posterior-only approach.

CONCLUSIONS

The advantage of a midline posterior approach is the ability to perform a lumbosacral reconstruction, necessary in cases in which the S-1 body is iatrogenically disrupted during tumor resection.

Hemipelvectomy- only a salvage therapy?

After the first hemipelvectomy in 1891 significant advances have been made in the fields of preoperative diagnosis, surgical technique and adjuvant treatment in patients with pelvic tumors. The challenging surgical removal of these rare malignant bone or soft tissue tumors accompanied by interdisciplinary therapy is mostly the only chance of cure, but bares the risk of intensive bleeding and infection. The reconstruction after hemipelvectomy is of importance for the later outcome and quality of life for the patient. Here, plastic surgery with microvascular free flaps or local rotational flaps improved the reconstruction and reduced infection rates. Average local recurrence rates of 14% demonstrate good surgical results, but 5 year survival rates of only 50% are described for some tumor entities, showing the importance of a multimodal collaboration. On a basis of a selective literature review the history, indications, treatment options and outcome of hemipelvectomies are presented.

The Friedman-Eilber resection arthroplasty of the pelvis

It has been argued that internal hemipelvectomy without reconstruction of the pelvic ring leads to poor ambulation and inferior patient acceptance. To determine the accuracy of this contention, we posed the following questions: First, how effectively does a typical patient ambulate following this procedure? Second, what is the typical functional capacity of a patient following internal hemipelvectomy? In the spring of 2006, we obtained video documentation of eight patients who had undergone resection arthroplasty of the hemipelvis seen in our clinic during routine clinical followup. The minimum followup in 2006 was 1.1 years (mean, 8.2 years; range, 1.1-22.7 years); at the time of last followup in 2008 the minimum followup was 2.9 years (mean, 9.8 years; range, 2.9-24.5 years). At last followup seven of the eight patients were without pain, and were able to walk without supports. The remaining patient used narcotic medication and a cane or crutch only occasionally. The mean MSTS score at the time of most recent followup was 73.3% of normal (range 53.3-80.0%; mean raw score was 22.0; range 16-24). All eight patients ultimately returned to gainful employment. These observations demonstrate independent painless ambulation and acceptable function is possible following resection arthroplasty of the hemipelvis.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Periacetabular limb salvage for malignant bone tumours

PURPOSE

To evaluate treatment outcomes in primary malignant periacetabular bone tumour removal and limb salvage with or without bone-graft reconstruction.

METHODS

A total of 13 patients were treated for malignant periacetabular bone tumours at Siriraj Hospital, Bangkok, Thailand. The diagnoses were chondrosarcoma (n=8), Ewing's sarcoma (n=2), osteosarcoma (n=1), well-differentiated osteosarcoma (n=1), and malignant giant cell tumour (n=1). 11 patients did not undergo reconstruction following tumour resection; 2 patients received fibular bone grafts bridging the periacetabulum to the remaining sacrum. Adjuvant chemotherapy was administered for high-grade malignant tumours, and postoperative radiation therapy was performed on patients with a closed surgical margin.

RESULTS

At a mean follow-up of 24.3 months (range, 8.9-43.9 months), 9 patients remained disease-free, 3 had died of the disease, and one was alive with disease. According to the Musculoskeletal Tumor Society classification system, the mean functional analysis at final follow-up was 68.7%. Patients who underwent internal hemipelvectomy experienced a subsequent leg-length discrepancy ranging from 3 to 10 cm. Four patients had complications (one each for deep wound infection, skin necrosis, seroma, and vascular spasms) and were successfully treated with multiple debridements and appropriate antibiotics. Three patients had local recurrences; one required a classic hemipelvectomy.

CONCLUSION

Malignant periacetabular tumours are difficult to manage. Functional results of our patients with no reconstruction or with bone-graft bridging were fair. Patients undergoing internal hemipelvectomy may experience leg-length discrepancies, which can be balanced with shoe lifts.

The swing procedure for pelvic ring reconstruction following tumour excision

AIM

High grade periacetabular osteosarcomas extending to the sacro-iliac region present a difficult management problem. We describe our experience of the swing procedure as a method of limb salvage.

METHOD

The procedure was performed on three patients with stage II B osteosarcoma.

RESULTS

Functional outcome was poor in all three with a mean Musculoskeletal Tumor Society score of 29% (27-30) at last review. All three developed local recurrence and one developed pulmonary metastases. The mean disease free interval post-operatively was 4.7 months (4-6) and they died of their disease at a mean of 10 months (5-16).

CONCLUSIONS

This form of limb salvage is technically demanding and carries a high morbidity. Functional outcome is poor and the prognosis for this group of patients is not improved by surgery. Alternative treatment options are discussed.

Osteosarcoma of the pelvis: experience of the Cooperative Osteosarcoma Study Group

PURPOSE

To define patients and tumor characteristics as well as therapy results, patients with pelvic osteosarcoma who were registered in the Cooperative Osteosarcoma Study Group (COSS) were analyzed.

PATIENTS AND METHODS

Sixty-seven patients with a high-grade pelvic osteosarcoma were eligible for this analysis. Fifteen patients had primary metastases. All patients received chemotherapy according to COSS protocols. Thirty-eight patients underwent limb-sparing surgery, 12 patients underwent hemipelvectomy, and 17 patients did not undergo definitive surgery. Eleven patients received irradiation to the primary tumor site: four postoperatively and seven as the only form of local therapy.

RESULTS

Local failure occurred in 47 of all 67 patients (70%) and in 31 of 50 patients (62%) who underwent definitive surgery. Five-year overall survival (OS) and progression-free survival rates were 27% and 19%, respectively. Large tumor size (P =.0137), primary metastases (P =.0001), and no or intralesional surgery (P <.0001) were poor prognostic factors. In 30 patients with no or intralesional surgery, 11 patients with radiotherapy had better OS than 19 patients without radiotherapy (P =.0033). Among the variables, primary metastasis, large tumor, no or intralesional surgery, no radiotherapy, existence of primary metastasis (relative risk [RR] = 3.456; P =.0009), surgical margin (intralesional or no surgical excision; RR = 5.619; P <.0001), and no radiotherapy (RR = 4.196; P =.0059) were independent poor prognostic factors.

CONCLUSION

An operative approach with wide or marginal margins improves local control and OS. If the surgical margin is intralesional or excision is impossible, additional radiotherapy has a positive influence on prognosis.