Reconstruction of the pelvic ring with vascularized double-strut fibular flap following internal hemipelvectomy

Internal hemipelvectomy: A single institution's learning curve and longitudinal experience

BACKGROUND AND OBJECTIVES

Wide margin resection for pelvic tumors via internal hemipelvectomy is among the most technically challenging procedures in orthopedic oncology. As such, surgeon experience and technique invariably affect patient outcomes. The aim of this clinical study was to assess how an individual surgeon's experiences and advancements in technology and techniques in the treatment of internal hemipelvectomy have impacted patient outcomes at our institution.

METHODS

This study retrospectively examined a single tertiary academic institution's consecutive longitudinal experience with internal hemipelvectomy for primary sarcoma or pelvic metastases over a 26-year period between the years 1994 and 2020. Outcomes were assessed using two separate techniques. The first stratified patients into cohorts based on the date of surgery with three distinct "eras" ("early," "middle," and "modern"), which reflect the implementation of new techniques, including three-dimensional (3D) computer navigation and cutting guide technology into our clinical practice. The second method of cohort selection grouped patients based on each surgeon's case experience with internal hemipelvectomy ("inexperienced," "developing," and "experienced"). Primary endpoints included margin status, complication profiles, and long-term oncologic outcomes. Whole group multivariate analysis was used to evaluate variables predicting blood loss, operative time, tumor-free survival, and mortality.

RESULTS

A total of 72 patients who underwent internal hemipelvectomy were identified. Of these patients, 24 had surgery between 1994 and 2007 (early), 28 between 2007 and 2015 (middle), and 20 between 2016 and 2020 (modern). Twenty-eight patients had surgery while the surgeon was still inexperienced, 24 while developing, and 20 when experienced. Evaluation by era demonstrated that a greater proportion of patients were indicated for surgery for oligometastatic disease in the modern era (0% vs. 14.3% vs. 35%, p = 0.022). Fewer modern cases utilized freehand resection (100% vs. 75% vs. 55%, p = 0.012), while instead opting for more frequent utilization of computer navigation (0% vs. 25% vs. 20%, p = 0.012), and customized 3D-printed cutting guides (0% vs. 0% vs. 25%, p =  0.002). Similarly, there was a decline in the rate of massive blood loss observed (72.2% vs. 30.8% vs. 35%, p = 0.016), and interdisciplinary collaboration with a general surgeon for pelvic dissection became more common (4.2% vs. 32.1% vs. 85%, p < 0.001). Local recurrence was less prevalent in patients treated in middle and modern eras (50% vs. 15.4% vs. 25%, p =  0.045). When stratifying by case experience, surgeries performed by experienced surgeons were less frequently complicated by massive blood loss (66.7% vs. 40% vs. 20%, p = 0.007) and more often involved a general surgeon for pelvic dissection (17.9% vs. 37.5% vs. 65%, p = 0.004). Whole group multivariate analysis demonstrated that the use of patient-specific instrumentation (PSI) predicted lower intraoperative blood loss (p = 0.040). However, surgeon experience had no significant effect on operative time (p = 0.125), tumor-free survival (p = 0.501), or overall patient survival (p = 0.735).

CONCLUSION

While our institution continues to utilize neoadjuvant and adjuvant therapies following current guideline-based care, we have noticed changing trends from early to modern periods. With the advent of new technologies, we have seen a decline in freehand resections for hemipelvectomy procedures, and a transition to utilizing more 3D navigation and customized 3D cutting guides. Furthermore, we have employed the use of an interdisciplinary team approach more regularly for these complicated cases. Although our results do not demonstrate a significant change in perioperative outcomes over the years, our institution's willingness to treat more complex cases likely obscures the benefits of surgeon experience and recent technological advances for patient outcomes.

The outcome of type 1 pelvic resection and reconstruction with pedicle screw-rod system without bone grafting in malignant pelvic tumour: A case series and short term review

INTRODUCTION

There is no consensus regarding the reconstruction method for type 1 resections around the pelvis. Various methods are currently used, such as resection without reconstruction, bone graft (autologous, recycled, allograft) with simple fixation, and pedicle screw-rod fixation with or without bone grafting. We aim to study the outcome of pedicle screw-rod reconstruction without bone grafting in type 1 pelvic resections involving sacroiliac joint to show that pedicle screw-rod construct alone is stable and has low risk of failure.

MATERIAL AND METHODS

This is a retrospective review of eight patients who underwent type 1 resection of malignant pelvic tumours and reconstruction with a pedicle screw-rod system between 2011 and 2018. All patients who underwent type 1 resection and reconstruction with pedicle screw without bone grafting were included into this study. We reported their clinical (complication and radiological outcome), oncological (local recurrence and metastasis), and functional outcome based on Musculoskeletal Tumour Society Score (MSTS) and The Toronto Extremity Salvage Score (TESS) at their last follow-up.

RESULTS

Eight patients were recruited into the study. The mean follow-up period was 58.5 months (range: 40 - 121 months). There were three postoperative complications in three different patients: superficial infection, surgical hernia with ipsilateral femoral avascular necrosis (AVN), and femoral nerve injury. At the end of the study period, one patient passed away due to disease progression, one patient was alive with disease, and the rest were disease-free. Mean MSTS score during last follow-up was 77.1% (range: 66.7% - 93.3%), while mean TESS score was 75.6% range (63.3% - 80.2%). There were no cases of implant failure.

CONCLUSION

Type 1 pelvic reconstruction with a pedicle screw-rod system is stable without a concurrent biological reconstruction, and it is feasible, with few complications, and an excellent functional outcome.

Multidisciplinary Approach to Hemipelvectomy for Pelvic Sarcomas

» Pelvic sarcomas are a rare and diverse group of tumors in terms of size and histology.» Pelvic sarcomas present a treatment challenge to the orthopaedic oncologist.» The size and location of these tumors require a varied approach to resection and reconstruction, but the tumor's proximity to other internal structures within the pelvis (e.g., the bladder, the iliac vessels, and the bowel) makes extrication demanding.» The ideal treatment requires assembling a hemipelvectomy team that consists of an orthopaedic oncologist, a surgical oncologist, a urologist, a vascular surgeon, a gynecologic oncologist, a plastic and reconstructive surgeon, a dedicated anesthesia team, and a dedicated rehabilitation physical therapy team. Each member can use his or her expertise to address the individual aspects of the pelvic resection and achieve the optimal oncologic and functional outcome.

Pelvic ring reconstruction with double-barreled fibular free flap: A systematic review

INTRODUCTION

Pelvic ring reconstruction after internal hemipelvectomy is an extremely challenging surgical procedure, and mandatory reconstruction is to provide a durable and pain-free functional outcome, especially for young, active patients. One of the most widely employed techniques is reconstruction with a double-barreled fibular free flap (DBF). The aim of our work was an in-depth analysis of the outcome of pelvic ring reconstruction performed using the above-mentioned method, in particular looking for a correlation between the fixation technique and either ambulation status or complications.

MATERIALS AND METHODS

A systematic review was performed in November 2020 using PubMed and MedLine Ovid databases according to the PRISMA guidelines and the results were statistically analyzed.

RESULTS

Studies were published between 1994 and 2015. A DBF was used in each case, with a total of 30 patients. Reconstruction was performed with screws in 13 cases, Cotrel-Dubousset rod fixation in 6, screws and plate in 5, screws with external fixation in 4, and ISOLA in 2. Follow-up time ranged from 3 to 131 months. Functional outcome was excellent in 4 patients and good in 26 patients. Statistical analysis showed no statistical evidence of existing correlation between fixation technique and complications (p = .873), while statistical correlation between age and fixation technique was found (p < .001).

CONCLUSION

Reconstruction of pelvic ring with DBF provides an overall good functional outcome. Our data indicate that there is no statistical evidence of existing correlation between the fixation technique and either complications or ambulation status.

Comparison of free vascularized fibular flaps and allograft fibular strut grafts to supplement spinopelvic reconstruction for sacral malignancies

AIMS

Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques.

METHODS

We reviewed 44 patients (23 female, 21 male) with a mean age of 40 years (SD 17), who underwent en bloc sacrectomy for a malignant tumour of the sacrum with a reconstruction using a total (n = 20), subtotal (n = 2), or hemicathedral (n = 25) technique. The reconstructions were supplemented with a FVF in 25 patients (57%) and an AFS in 19 patients (43%). The mean length of the strut graft was 13 cm (SD 4). The mean follow-up was seven years (SD 5).

RESULTS

There was no difference in the mean age, sex, length of graft, size of the tumour, or the proportion of patients with a history of treatment with radiotherapy in the two groups. Reconstruction using an AFS was associated with nonunion (odds ratio 7.464 (95% confidence interval (CI) 1.77 to 31.36); p = 0.007) and a significantly longer mean time to union (12 months (SD 3) vs eight (SD 3); p = 0.001) compared with a reconstruction using a FVF. Revision for a pseudoarthrosis was more likely to occur in the AFS group compared with the FVF group (hazard ratio 3.84 (95% CI 0.74 to 19.80); p = 0.109); however, this was not significant. Following the procedure, 32 patients (78%) were mobile with a mean Musculoskeletal Tumor Society Score 93 of 52% (SD 24%). There was a significantly higher mean score in patients reconstructed with a FVF compared with an AFS (62% vs 42%; p = 0.003).

CONCLUSION

Supplementation of spinopelvic reconstruction with a FVF was associated with a shorter time to union and a trend towards a reduced risk of hardware failure secondary to nonunion compared with reconstruction using an AFS. Spinopelvic fixation supplemented with a FVF is our preferred technique for reconstruction following resection of a sacral tumour. Cite this article: Bone Joint J 2021;103-B(8):1414-1420.

Remaining spine deformity after revision surgery for pelvic reconstruction and spinopelvic fixation: illustrative case

BACKGROUND

Pelvic deformity after resection of malignant pelvic tumors causes scoliosis. Although the central sacral vertical line (CSVL) is often used to evaluate the coronal alignment and determine the treatment strategy for scoliosis, it is not clear whether the CSVL is a suitable coronal reference axis in cases with pelvic deformity. This report proposes a new coronal reference axis for use in cases with pelvic deformity and discusses the pathologies of spinal deformity remaining after revision surgery.

OBSERVATIONS

A 14-year-old boy who had undergone internal hemipelvectomy and pelvic ring reconstruction 2 years prior was referred to our hospital with severe back pain. His physical and radiographic examinations revealed severe scoliosis with pelvic deformity. The authors planned a surgical strategy based on the CSVL and performed pelvic ring reconstruction using free vascularized fibula graft and spinopelvic fixation from L5 to the pelvis. After the procedure, although the patient’s back pain was relieved, his scoliosis persisted. At the latest follow-up, his spinal deformity correction was acceptable with corset bracing. Therefore, the authors did not perform additional surgeries.

LESSONS

The CSVL may not be appropriate for evaluating coronal alignment in cases with pelvic deformity. Accurate preoperative planning is required to correct spinal deformities with pelvic deformity.

Internal Hemipelvectomy and Pelvic Reconstruction With Non-Vascularized Fibular Graft for Chondrosarcoma Ilium

Chondrosarcoma is the third most common primary malignant bone tumor. The pelvis is the most common site with iliac bone being frequently involved. Hindquarter amputation was the standard treatment for pelvic osteosarcoma for years. Resection of tumors with wide margins gained popularity with advances in the medical field. The only resection without reconstruction of the pelvis has its own demerits which paved way for methods of reconstruction. One of these is pelvic reconstruction with non-vascularised fibular graft among many other methods, which is simple, cost-effective, and has a good functional outcome. Here, we are reporting a case of exophytic chondrosarcoma of intermediate grade in ilium in a 19-year-old male for whom internal hemipelvectomy (Enneking and Dunham type 1) and pelvic reconstruction with non-vascularised fibular graft was done with the excellent functional and radiological outcome, with a two-year follow-up.

Does Adding Femoral Lengthening at the Time of Rotation Hip Transposition After Periacetabular Tumor Resection Allow for Restoration of Limb Length and Function? Interim Results of a Modified Hip Transposition Procedure

BACKGROUND

Reconstruction after pelvic tumor resection of the acetabulum is challenging. Previous methods of hip transposition after acetabular resection have the advantages of reducing wound complications and infections of the allograft or metal endoprosthesis but were associated with substantial limb length discrepancy. We therefore developed a modification of this procedure, rotation hip transposition after femur lengthening, to address limb length, and we wished to evaluate its effectiveness in terms of complications and functional outcomes.

QUESTIONS/PURPOSES

In this study, we asked: (1) What were the Musculoskeletal Tumor Society scores after this reconstruction method was used? (2) What complications occurred after this reconstruction method was used? (3) What proportion of patients achieved solid arthrodesis (as opposed to pseudarthrosis) with the sacrum and solid union of the femur? (4) What were the results with respect to limb length after a minimum follow-up of 2 years?

METHODS

From 2011 to 2017, 83 patients with an aggressive benign or primary malignant tumor involving the acetabulum were treated in our institution. Of those, 23% (19 of 83) were treated with rotation hip transposition after femur lengthening and were considered for this retrospective study; 15 were available at a minimum follow-up of 2 years (median [range], 49 months [24 to 97 months]), and four died of lung metastases before 2 years. No patients were lost to follow-up before 2 years. During the period in question, the general indications for this approach were primary nonmetastatic malignant bone tumor or a locally aggressive benign bone tumor that could not be treated adequately with curettage. There were seven men and 12 women with a median age of 43 years. Nine patients underwent Zones I + II resection, eight patients had Zones I + II + III resection, and two received Zones II + III resection. After tumor resection, rotation hip transposition after femur lengthening reconstruction was performed, which included two steps. The first step was to lengthen the femur with the insertion of an allograft. Two methods were used to achieve limb lengthening: a "Z" osteotomy and a transverse osteotomy. The second step was to take the hip transposition and rotate the femoral head posteriorly 10° to 20°. The median (range) operative time was 510 minutes (330 to 925 minutes). The median intraoperative blood loss was 4000 mL (1800 to 7000 mL). We performed a chart review on the 15 available patients for clinical and radiographic assessment of functional outcomes and complications. Arthrodesis and leg length discrepancy were evaluated radiographically.

RESULTS

The median (range) Musculoskeletal Tumor Society score was 21 points (17 to 30). Eleven of 19 patients developed procedure-related complications, including six patients with allograft nonunion, two with deep infection, two with delayed skin healing, and one with a hematoma. Two patients had minor additional surgical interventions without the removal of any implants. Local recurrences developed in four patients, and all four died of disease. All seven patients treated with a Z osteotomy had bone union. Among the eight patients with transverse osteotomy, bone union did not occur in six patients. After hip transposition, stable iliofemoral arthrodesis was achieved in seven patients. Pseudarthrosis developed in the remaining eight patients. The median (range) lower limb length discrepancy at the last follow-up visit or death was 8 mm (1 to 42 mm).

CONCLUSION

Although complex and challenging, rotation hip transposition after femur lengthening reconstruction with a Z osteotomy provides acceptable functional outcomes with complications that are within expectations for resection of pelvic tumors involving the acetabulum. Because of the magnitude and complexity of this technique, we believe it should be used primarily for patients with a favorable prognosis, both locally and systemically. This innovative procedure may be useful to other surgeons if larger numbers of patients and longer-term follow-up confirm our results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Pelvic Ring Reconstruction After Iliac or Iliosacral Resection of Pediatric Pelvic Ewing Sarcoma: Use of a Double-Barreled Free Vascularized Fibular Graft and Minimal Spinal Instrumentation

BACKGROUND

In patients undergoing iliosacral resections, pelvic ring reconstruction can maintain stability of the pelvis and spinal column, which is expected to achieve good functional outcomes. However, no optimal reconstruction method has been established. We aimed to analyze the outcome of pelvic ring reconstruction using double-barreled free vascularized fibular graft (FVFG) and internal fixation after iliosacral resections in children.

METHODS

We retrospectively reviewed 16 children with pelvic Ewing sarcoma who underwent pelvic ring reconstruction using double-barreled FVFG after iliosacral resection. The fibular graft was placed between the supraacetabular region distally and the remaining ilium or sacrum proximally. The stability of the remaining pelvis and spinal column was provided by minimal spinal instrumentation.

RESULTS

Eleven Type-I and 5 Type-I+IV resections were performed for 10 boys and 6 girls, who had a mean age of 13.4 years (range, 10 to 18 years). The mean follow-up was 49.8 months (range, 28 to 96 months). At the time of the final follow-up, 14 patients were alive and 2 patients had died of disease. The mean time for bone union was 9 months (range, 6 to 12 months). Graft hypertrophy was evident in all patients at 12 months. The median Musculoskeletal Tumor Society (MSTS) score at the time of the final follow-up was 80% (range, 60% to 96.6%). Seven patients had complications. Three complications required reoperation: 1 deep infection, 1 hematoma, and 1 wound dehiscence. Three patients had disease relapse in terms of lung metastases.

CONCLUSIONS

This reconstruction method can achieve a high rate of bone union and can provide good functional outcomes following resection of pediatric pelvic Ewing sarcomas with iliosacral involvement. Complications are usually manageable without a need for revision surgical procedures.

LEVEL OF EVIDENCE

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

Reconstruction of the pelvic ring in iliac or iliosacral resections: allograft or autograft?

BACKGROUND

The necessity to reconstruct the pelvic ring after an iliac or iliosacral resection is still debated. Different reconstructive techniques are available, including autologous and homologous graft and custom-made prosthesis. The aim of this study was to evaluate the functional outcome and complications of patients who underwent resection of iliac bone and part of the sacrum for primary bone tumour and reconstruction with an allograft or autograft.

METHODS

We retrospectively evaluated 18 patients (10 males and 8 female) with a mean age of 28 years (range 9-56) who were operated between 1992 and 2015. Six patients were reconstructed with an autograft (Group A) and 12 patients with an allograft (Group B). All complications were recorded. At final follow-up, patients with the original reconstruction still in site were functionally evaluated with MSTS Score.

RESULTS

Mean follow-up time was 107 months (range 4-221). Two patients (11.1%) had an external hemipelvectomy for local recurrence, and 3 patients died of the disease. Mean MSTS Score was comparable between the two groups 21.7 (range 20-25) in Group A and 19.9 (range 4-28) in Group B. Patients with partial sacral resection had an increased risk of local recurrence and lower MSTS Score [15.5 (range 7-20) vs. 22.2 (range 4-28)].

CONCLUSIONS

Biological reconstruction of pelvic ring with autologous or homologous bone graft gives acceptable functional results. However, the decision on how to reconstruct the pelvic ring after iliac resection should be taken on a patient-by-patient basis.

Free tibia and fibula-fillet-of-leg flap for pelvic ring reconstruction: A case report

Pelvic sarcoma resections present large and complex defects, which are a challenge to reconstruct. At times, these cancers are treated with external hemipelvectomy, and both the soft tissue and bony framework of the pelvic ring must be addressed. The purpose of this case report is to describe the use of a free tibia and fibula-fillet-of-leg flap for pelvic ring reconstruction, performed to enhance the quality of life of a patient following hemipelvectomy. A 50-year-old female with advanced stage undifferentiated pleomorphic sarcoma of the left thigh and pelvis underwent free vascularized tibia and fibula-fillet-of-leg flap, including 21 cm of bone length and 21 cm long and full circumferential soft tissues of the leg, accompanying the bone, for the reconstruction of the bony pelvis and soft tissue. Postoperatively, the patient had no surgical complications, was followed for 6 months and went on to have bony healing, and was able to sit prior to disease progression and eventual death from metastatic disease. In the reported case, we have shown that composite tibia-fibula free flap with lower leg soft tissues may be a viable option for the reconstruction of massive external hemipelvectomy defects.

Free latissimus dorsi musculocutaneous flap for external hemipelvectomy reconstruction

INTRODUCTION

External hemipelvectomy is one of the most extensive surgical procedures for locally advanced pelvic tumors. Stump coverage with the local tissues can be difficult in recurrent cases. Herein, we report our experience with immediate stump coverage using a free latissimus dorsi musculocutaneous (LDMC) flap after external hemipelvectomy for recurrent pelvic malignancies.

METHODS

Six patients underwent external hemipelvectomy and immediate reconstruction using a free LDMC flap between November 2012 and June 2017. The mean age of the patients was 65 years (range: 63-69 years). The primary tumors were myxoid liposarcoma, chondrosarcoma, osteosarcoma, squamous cell carcinoma, and pleomorphic liposarcoma. A free LDMC flap was harvested from the ipsilateral back and transferred to the defect. When an intercostal nerve was found at the recipient site, the thoracodorsal nerve was coaptated with the intercostal nerve to reinnervate the muscle.

RESULTS

The mean flap size was 23 × 10 cm and the range was 20 × 8-27 × 13.5 cm. The contralateral deep inferior epigastric vessels were used as recipient vessels in all patients. Thoracodorsal-intercostal nerve coaptation was performed in 2 patients. The flap survived in all patients. Three patients had complications of abscess formation. No patient developed postoperative hernia.

CONCLUSION

Although it is challenging to do reconstruction after external hemipelvectomy, a free LDMC flap has several advantages, including a large coverage area, stability of circulation, ease of elevation, and preservation of the strength of the remaining abdominal wall. Technical tips for selecting anastomosis vessels are important and nerve coaptation could be effective.

Pelvic reconstruction with different rod-screw systems following Enneking type I/I + IV resection: a clinical study

The mechanical outcomes of patients with pelvic bone tumors involving zone I or zone I + IV who received resection and different reconstructions are not clear. Therefore, the purpose of this study was to compare the outcomes of different rod-screw systems in reconstruction for these patients, and evaluate the relative risk of mechanical failure for them. We reviewed 30 patients for a mean duration of 40.4 months of follow-up (range, 13.1–162.2 months), five patients had mechanical complications. The mechanical survival rate of two-rod and four-screw (TRFS) group was significantly higher than one-rod and two-screw (ORTS) group (p = 0.000). The implant survival rate was correlated with ages (p = 0.010), younger people are more likely to fail. Thus, TRFS fixation for pelvic reconstruction after Enneking type I/I + IV resection can provide better short to long-term mechanical stability compared with ORTS fixation, the strength of ORTS fixation is not enough. In addition, biological reconstruction such as autologous bone graft is recommended for the patients who are younger or suffered from benign tumor. As for the patients who are older, with malignant tumors, underwent adjuvant radiotherapy or chemotherapy, functional reconstruction with bone cement is a good choice.

Intercalary reconstruction of femur after tumour resection: is a vascularized fibular autograft plus allograft a long-lasting solution?

Aims

After intercalary resection of a bone tumour from the femur, reconstruction with a vascularized fibular graft (VFG) and massive allograft is considered a reliable method of treatment. However, little is known about the long-term outcome of this procedure. The aims of this study were to determine whether the morbidity of this procedure was comparable to that of other reconstructive techniques, if it was possible to achieve a satisfactory functional result, and whether biological reconstruction with a VFG and massive allograft could achieve a durable, long-lasting reconstruction.

Patients and Methods

A total of 23 patients with a mean age of 16 years (five to 40) who had undergone resection of an intercalary bone tumour of the femur and reconstruction with a VFG and allograft were reviewed clinically and radiologically. The mean follow-up was 141 months (24 to 313). The mean length of the fibular graft was 18 cm (12 to 29). Full weight-bearing without a brace was allowed after a mean of 13 months (seven to 26).

Results

At final follow-up, the mean Musculoskeletal Tumor Society Score of 22 evaluable patients was 94% (73 to 100). Eight major complications, five fractures (21.7%), and three nonunions (13%) were seen in seven patients (30.4%). Revision-free survival was 72.3% at five, ten, and 15 years, with fracture and nonunion needing surgery as failure endpoints. Overall survival, with removal of allograft or amputation as failure endpoints, was 94.4% at five, ten, and 15 years.

Discussion

There were no complications needing surgical revision after five years had elapsed from surgery, suggesting that the mechanical strength of the implant improves with time, thereby decreasing the risk of complications. In young patients with an intercalary bone tumour of the femur, combining a VFG and massive allograft may result in a reconstruction that lasts a lifetime. Cite this article: Bone Joint J 2018;100-B:378-86.

Ewings sarcoma of ilium: Resection and reconstruction with femoral head allograft

Ewing's sarcoma is a common malignant bone tumor seen in 5-15 years age group. It often arises from diaphysis of long bones. Ewing's sarcoma arising from the ilium is very rare, and it has an unfavourable prognosis. We present a rare case report of Ewings sarcoma of ilium with no metastasis in a two and a half year old boy, who was treated with neoadjuvant chemotherapy followed by surgical excision of the tumor and reconstruction using allograft from the femoral head fixed with multiple k-wires and screw. The patient is disease free at one year follow up and the allograft has taken the shape of growing ilium and excellent functionality and gait with minimal limp. Through this report, we emphasize on the occurrence of Ewings sarcoma in unusual site and resection and reconstruction of the tumor utilizing the allograft.

Outcomes and Complications of Reconstruction with Use of Free Vascularized Fibular Graft for Spinal and Pelvic Defects Following Resection of a Malignant Tumor

BACKGROUND

Following resection of malignant tumors of the spine and pelvis, reconstructive surgeons often face large structural defects. Unlike reconstruction in the extremities, wherein a free vascularized fibular graft (FVFG) is a highly utilized option for segmental osseous reconstruction, there are limited data on the use of an FVFG in the spine and pelvis. The aim of this study was to review our institution's experience with reconstruction with use of an FVFG following oncological resection in the spine and pelvis.

METHODS

We reviewed 24 cases involving the use of an FVFG in reconstruction of segmental osseous defects of the spine and pelvis following oncological resection from 2000 to 2015. The cohort consisted of 12 male and 12 female patients with a mean age of 37 years and a mean follow-up of 5 years. Fifty-four percent of the reconstructions were spinopelvic or sacropelvic.

RESULTS

The overall 2, 5, and 10-year rate of survival was 76%, 55%, and 37%, respectively. With regard to disease-free survival, the overall 2, 5, and 10-year rate was 81%, 72%, and 48%. The overall rate of union was 86%, with a mean time to union of 7 months. Complications were common, with 83% of the patients sustaining at least 1 postoperative complication. Following the procedure, the mean Musculoskeletal Tumor Society rating was 53%.

CONCLUSIONS

An FVFG provides a durable means of reconstruction of osseous defects in the spine and pelvis. Although patient function was acceptable following these large reconstructions, the rate of postoperative complications was high.

LEVEL OF EVIDENCE

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

Mechanical comparison of iliosacral reconstruction techniques after sarcoma resection

BACKGROUND

Reconstruction of iliosacral defects following oncologic resection is a difficult clinical problem associated with a high incidence of failure. Technical approaches to this problem are heterogeneous and evidence supporting specific techniques is sparse. Maximizing construct stability may improve union rates and functional outcomes. The purpose of this study is to compare construct stiffness, load to failure, and mechanism of failure between two methods of iliosacral reconstruction in an ex-vivo model to determine if either is mechanically superior.

METHODS

Eight third-generation composite pelves reconstructed with a plate-and-screw technique were tested against seven pelves reconstructed with a minimal spinal instrumentation technique using axial loading in a double-leg stance model.

FINDINGS

The pelves from the plate group demonstrated higher stiffness in the direction of applied load (102.9 vs. 66.8N/mm; p=0.010) and endured a significantly larger maximum force (1416 vs. 1059N; p=0.015) than the rod group prior to failure. Subjectively, the rod-reconstructed pelves were noted to be rotationally unconstrained while pivoting around their single point-of fixation in each segment leading to earlier failure.

INTERPRETATION

Plate-reconstruction was mechanically superior to spinal instrumentation in the manner performed in this study. More than one point of fixation in each segment should be achieved to minimize the risk of rotational deformation.

A double-barrelled fibula graft restoring pelvic stability after late posterior ring instability related to a surgical treated osteitis pubis: a case report

BACKGROUND

Osteitis pubis or symphysitis pubis is a rare occurring non-infectious inflammation of the symphysis, the adjacent pubic bones and surrounding tissue. The therapy might be conservative or surgical by a resection of the symphysis and involved parts of the pubic bone. Nevertheless, this resection might lead to an anterior instability impairing the posterior arch and the sacroiliac joints in the aftermath.

CASE PRESENTATION

Here, we report about a 50-year-old women suffering from osteitis pubis treated by wedge resection of the symphysis and parts of the pubic bone. To maintain stability and for local antibiotic treatment a cement spacer was implemented. By clinical inconspicuous findings and the patient's desire, no further surgery was performed. However, 2 years after surgery the spacer dislocated and the patient complained about pain in the posterior arch due to an impaired mobility. Reconstruction surgery was planned including the bridging of the accrued space with a vascularized double-barrelled fibula graft, plate osteosynthesis and rectus abdominis flap coverage. The performed surgery led to pain relief and increased mobility.

CONCLUSION

The present case highlights the possible complication of surgical treated osteitis pubis leading to anterior arch instability affecting the posterior arch and thus impairing pelvic ring stability and patient mobility. Furthermore, we describe an opportunity to treat this complication or other etiologies contributing to anterior pelvic ring stability with large bone defects using a vascularized double-barrelled fibula graft to restore pelvic stability.

Pelvic ring reconstruction with a double-barreled free vascularized fibula graft after resection of malignant pelvic bone tumor

INTRODUCTION

In patients undergoing limb-salvage internal hemipelvectomy, pelvic ring reconstruction is mandatory to maintain the stability of the pelvis and the spinal column, which finally expected to achieve a good functional outcome. However, no optimal reconstruction method has been established. In addition, no previous reports have highlighted the long-term complications of pelvic ring reconstruction after internal hemipelvectomy. We aimed to analyze the outcome of pelvic ring reconstruction using a double-barreled free vascularized fibula graft (VFG) after internal hemipelvectomy with special reference to long-term complications.

MATERIALS AND METHODS

We conducted a retrospective review of 9 consecutive patients (5 male, 4 female; mean age 31 years) who underwent pelvic ring reconstruction using a double-barreled free VFG after internal hemipelvectomy (P1, n = 4; P1 + 4, n = 3; P1 + 2, n = 2) at our institution between 1998 and 2013. The mean follow-up period was 55 months (range 3-131 months).

RESULTS

The mean length of the bone defect was 9 cm. The methods of fixation included a Cotrel-Dubosset rod (n = 4), screw (n = 3), and screw and plate (n = 2). Bone union was achieved in 5 of 8 patients (63 %) over a 1-year follow-up. The mean period required for bone union was 5.4 months (range 3-7 months). There were 3 early postoperative complications: 2 deep infections resulting in graft removal and 1 implant failure resulting in non-union. Among 3 patients, 2 developed scoliosis within 5 years. One patient developed lumbar disc hernia as a result of scoliosis, for which surgical intervention was required. The mean Musculoskeletal Tumor Society score was 57 % at the last follow-up.

CONCLUSIONS

In conclusion, this reconstruction method can achieve an early and high rate of bone union and provide good functional outcome. However, follow-up with careful attention to postoperative complications, including deep infection in the early postoperative period and spinal deformity in the long term, is necessary.

The use of extracorporeally irradiated autografts in pelvic reconstruction following tumour resection

The aim of this study was to evaluate the functional and oncological outcome of extracorporeally irradiated autografts used to reconstruct the pelvis after a P1/2 internal hemipelvectomy.

The study included 18 patients with a primary malignant bone tumour of the pelvis. There were 13 males and five females with a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic sarcoma, six a Ewing’s sarcoma, and five a chondrosarcoma. At a mean follow-up of 51.6 months (4 to 185), nine patients had died with metastatic disease while nine were free from disease. Local recurrence occurred in three patients all of whom eventually died of their disease. Deep infection occurred in three patients and required removal of their graft in two while the third underwent a hindquarter amputation for extensive flap necrosis.

The mean Musculoskeletal Tumor Society functional score of the 16 patients who could be followed-up for at least 12 months was 77% (50 to 90). Those 15 patients who completed the Toronto Extremity Salvage Score questionnaire had a mean score of 71% (53 to 85).

Extracorporeal irradiation and re-implantation of bone is a valid method of reconstruction after an internal hemipelvectomy. It has an acceptable morbidity and a functional outcome that compares favourably with other available reconstructive techniques.

Cite this article: Bone Joint J 2014;96-B:1404–10

A new type of reconstruction of the hemipelvis after Type 3 amputative sacrectomy using pedicled fibula

This is a technical note of pelvic reconstruction performed by an advanced multidisciplinary team. The authors report a new 3-stage reconstruction of the hemipelvis after Type 3 sacrectomy involving instrumented spinoiliac arthrodesis and pedicled fibula grafting in 2 patients.

The anterior stage of the procedure begins with a transabdominal approach to mobilize the viscera and to free up the tumor from the vessels. The posterior divisions of internal iliac vessels, the middle sacral vessels, and the lateral sacral vessels are then ligated. An anterior vertebrectomy is done at the appropriate level, followed by an anterior osteotomy through the lateral planed surgical margin of the sacrum close to the salvaged sacroiliac joint. The second stage includes a major sacral resection with lower-extremity amputation from the pubic symphysis through the intact side of the sacrum, ipsilateral pedicled fibula harvesting, and closure with an ipsilateral pedicled quadriceps flap. The final stage involves reconstruction with lumboiliac instrumentation. The pedicled fibular graft left from the second stage is then placed distally within the previously created iliopectineal docking site and proximally within the L-5 docking site.

The authors believe that this is a feasible and reproducible technique with theoretical advantages that have to be proved in the long-term follow-up.

Femur performed better than tibia in autologous transplantation during hemipelvis reconstruction

BACKGROUND

Pelvic reconstruction after hemipelvectomy can greatly improve the weight-bearing stability of the supporting skeleton and improve patients' quality of life. Although an autograft can be used to reconstruct pelvic defects, the most suitable choice of autograft, i.e., the use of either femur or tibia, has not been determined. We aimed to analyze the mechanical stresses of a pelvic ring reconstructed using femur or tibia after hemipelvectomy using finite element (FE) analysis.

METHODS

FE models of normal and reconstructed pelvis were established based on computed tomography images, and the stress distributions were analyzed under physiological loading from 0 to 500 N in both intact and restored pelvic models using femur or tibia.

RESULTS

The vertical displacement of the intact pelvis was less than that of reconstructed pelvis, but there was no significant difference between the two reconstructed models. In FE analysis, the stress distribution of the intact pelvic model was bilaterally symmetric and the maximum stresses were located at the sacroiliac joint, arcuate line, ischiatic ramus, and ischial tuberosity. The maximum stress in each part of the reconstructed pelvis greatly exceeded that of the intact model. The maximum von Mises stress of the femur was 13.9 MPa, and that of the tibia was 6.41 MPa. However, the stress distribution was different in the two types of reconstructed pelvises. The tibial reconstruction model induced concentrated stress on the tibia shaft making it more vulnerable to fracture. The maximum stress on the femur was concentrated on the connections between the femur and the screws.

CONCLUSIONS

From a biomechanical point of view, the reconstruction of hemipelvic defects with femur is a better choice.

Surgical technique: Iliosacral reconstruction with minimal spinal instrumentation

BACKGROUND

Posterior pelvic ring reconstruction can be challenging and controversial. The choice regarding whether to reconstruct and how to reconstitute the pelvic ring is unclear. Many methods provide stability but often are technically difficult and require excessive dissection. DESCRIPTION OF SURGICAL TECHNIQUE: This unique reconstructive technique uses the anterior aspect of the iliac crest with its attached muscle pedicle to provide a biologic scaffold for healing. The construct is secured with pedicle screws into the posterior column and S1 vertebral body with a spinal rod locked in compression. No additional fixation is used proximally into the lumbar spine. The iliac crest remains attached to the gluteus medius, allowing potential abductor function.

METHODS

We retrospectively reviewed six patients who underwent iliosacral resection with this reconstruction. The mean age of the patients was 41 years. Complications were recorded. One patient died 6 months postoperatively. Musculoskeletal Tumor Society 1993 (MSTS '93) score and Toronto Extremity Salvage Score (TESS) were obtained at a minimum 1-year followup in five patients. Healing was assessed radiographically. The minimum followup was 6 months (median, 33 months; range, 6-53 months).

RESULTS

The mean MSTS '93 score was 72% and mean TESS was 66. All posterior column graft sites healed. At last followup, four of the five surviving patients had a stable pseudarthrosis at the proximal sacral site. One patient had a local recurrence and experienced failure of instrumentation without collapse or rotation of the hemipelvis 3 years postoperatively.

CONCLUSIONS

This technique provides a simple way to reconstruct the pelvic ring after iliosacral resection with clinical outcomes comparable to those for other methods. The method is a potential alternative for reconstruction of the posterior pelvic ring after resecting the ilium although reliable healing of the sacral site needs to be improved.

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 outcome of pelvic reconstruction with non-vascularised fibular grafts after resection of bone tumours

We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature. Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts.

The non-vascularised fibular graft: a simple and successful method of reconstruction of the pelvic ring after internal hemipelvectomy

Internal hemipelvectomy is a standard treatment for malignant tumours of the pelvis. Reconstruction using a non-vascularised fibular graft is relatively straightforward compared to other techniques. We describe the surgical and functional outcomes for a series of ten patients who underwent an internal hemipelvectomy (type I or I/IV) with reconstruction by a non-vascularised fibular graft between 1996 and 2009. A key prerequisite for this procedure was a preserved sciatic notch, confirmed pre-operatively on MRI. Graft-host union was achieved in all patients with a single fibular graft, and in the lower graft where two grafts had been used. The mean time to union was 7.3 months (3 to 12). The upper graft did not unite in four of six cases where two grafts had been used. Seven patients were eventually able to walk without a stick. The mean post-operative Musculoskeletal Tumour Society score was 75.4% (16.7 to 96.7). There were no cases of deep post-operative infection. The mean pelvic shortening was 0.9 cm (0.2 to 3.4). Recurrent tumour occurred in three cases, and death from tumour-related disease occured in one. Patients who need an internal hemipelvectomy will do well if their pelvic ring is reconstructed with a non-vascularised fibular graft. The complication rate is low, and they attain a good functional outcome.

Reconstruction of massive oncologic defects using free fillet flaps

BACKGROUND

Forequarter and hind-limb amputations are used with curative and palliative intent in the setting of proximal limb, thorax, or truncal malignancies. For these large defects that require a free flap, the distal portions of these limbs can be harvested as fillet flaps and represent the "spare parts" concept of surgical reconstruction.

METHODS

The authors performed a retrospective review of 27 patients (mean age, 51.4 years) who had undergone immediate reconstruction with free fillet extremity flaps between 1991 and 2008. Seventeen patients received preoperative radiotherapy, and 21 received preoperative chemotherapy. Resections included seven hemipelvectomies, 16 forequarter amputations, and four hindquarter amputations.

RESULTS

The mean defect size was 1126 cm (range, 480 to 3500 cm). All 27 flaps survived and all wounds healed. Four patients (15 percent) had complications; three patients developed partial flap necrosis and required operative débridement, and there were two episodes of flap vascular compromise. Mean follow-up time was 14 months. One patient was lost to follow-up. Eight patients (30 percent) were still alive at the end of the study. The remaining 18 patients died within 22 months of resection, for a mean survival of 7 months. There was no cancer recurrence within the flap itself. Phantom pain occurred in 11 patients. At the time of discharge, pain, tissue necrosis, and infection were improved in all patients.

CONCLUSION

The use of the fillet flap is oncologically sound, has no associated donor sites, has an acceptable incidence of major complications, and allows for a healed wound with an improvement in the quality of life.

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.