The outcome of surgical treatment for peri-acetabular metastases

Management of metastatic bone disease of the pelvis: current concepts

PURPOSE

Metastatic disease of the pelvis is frequently associated with severe pain and impaired ambulatory function. Depending on the patient's characteristics, primary tumor, and metastatic pelvic disease, the treatment choice may be varied. This study aims to report on the current management options of metastatic pelvic disease.

METHODS

We comprehensively researched multiple databases and evaluated essential studies about current concepts of managing a metastatic bone disease of the pelvis, focusing on specific indications as well as on the result of treatment.

RESULTS

Pelvic metastases not in the periacetabular region can be managed with modification of weight-bearing, analgesics, bisphosphonates, chemotherapy and/or radiotherapy. Minimally invasive approaches include radiofrequency ablation, cryoablation, embolization, percutaneous osteoplasty, and percutaneous screw placement. Pathological or impending periacetabular fracture, excessive periacetabular bone defect, radioresistant tumor, and persistent debilitating pain despite non-surgical treatment and/or minimally invasive procedures can be managed with different surgical techniques. Overall, treatment can be divided into nonoperative, minimally invasive, and operative based on specific indications, the expectations of the patient and the lesion.

CONCLUSION

Different treatment modalities exist to manage metastatic pelvic bone disease. Decision-making for the most appropriate treatment should be made with a multidisciplinary approach based on a case-by-case basis.

The Modified Harrington Procedure for Metastatic Peri-Acetabular Bone Lesion Using a Novel Highly Porous Titanium Revision Shell with Long Lever Arm Screw

Background and Objectives: Peri-acetabular metastases often lead to significant pain and functional impairment. Surgical interventions, including the Harrington procedure, aim to address these challenges. This study evaluates a modified Harrington procedure using the MUTARS® PRS® (Pelvic Revision Shell) with an 8 mm fixation screw for severe acetabular defects resulting from metastatic lesions. Materials and Methods: Retrospective analysis of 12 patients treated between January 2020 and December 2023 was conducted. The procedure involved using the novel MUTARS® PRS® with an 8 mm in diameter dome screw (length 70-100 mm). Outcome measures included implant positioning changes, complication rates, functional outcomes, implant longevity, and patient survival. Radiological assessments were performed postoperatively, with follow-ups at 3, 6, 12 months, and annually thereafter. Results: Average follow-up was 15 ± 11 months, with 67% patient survival at 1 year and 44% at 2 years. Implant survivorship remained 100%. Harris Hip Score improved significantly from 37 ± 22 preoperatively to 75 ± 15 at the last follow-up. No revisions involving implant components were reported. Complications occurred in 5 of 12 patients. Overall, PRS® demonstrates effective osseous ingrowth, high primary stability, immediate full weight-bearing, and low complication rates. Conclusions: PRS® integrates facilitating osseous ingrowth for preferable long-term outcomes, while efficiently transmitting the weight-bearing load to the intact aspect of the pelvis using a long 8 mm lever screw, enhancing the primary stability of the construct. It proves to be an effective and reproducible technique for managing destructive metastatic lesions of the acetabulum and peri-acetabular region, even in irradiated bone.

Hip Reconstruction In Situ with Screws and Cement (HiRISC) construct to treat large acetabular bone defects

Aims

Large bone defects resulting from osteolysis, fractures, osteomyelitis, or metastases pose significant challenges in acetabular reconstruction for total hip arthroplasty. This study aimed to evaluate the survival and radiological outcomes of an acetabular reconstruction technique in patients at high risk of reconstruction failure (i.e. periprosthetic joint infection (PJI), poor bone stock, immunosuppressed patients), referred to as Hip Reconstruction In Situ with Screws and Cement (HiRISC). This involves a polyethylene liner embedded in cement-filled bone defects reinforced with screws and/or plates for enhanced fixation.

Methods

A retrospective chart review of 59 consecutive acetabular reconstructions was performed by four surgeons in a single institution from 18 October 2018 to 5 January 2023. Cases were classified based on the Paprosky classification, excluding type 1 cases (n = 26) and including types 2 or 3 for analysis (n = 33). Radiological loosening was evaluated by an orthopaedic surgeon who was not the operating surgeon, by comparing the immediate postoperative radiographs with the ones at latest follow-up. Mean follow-up was 557 days (SD 441; 31 to 1,707).

Results

Out of the 33 cases analyzed, six (18.2%) constructs required revision, with four revisions due to uncontrolled infection, one for dislocation, and one for aseptic loosening. Among the 27 non-revised constructs, only one showed wider radiolucencies compared to immediate postoperative radiographs, indicating potential loosening. Patients who underwent revision (n = 6) were significantly younger and had a higher BMI compared to those with non-revised constructs (p = 0.016 and p = 0.026, respectively). Sex, race, ethnicity, American Society of Anesthesiologists grade, infection status (patients with postoperative PJI diagnosis (septic) vs patients without such diagnosis (aseptic)), and mean follow-up did not significantly differ between revised and non-revised groups.

Conclusion

The HiRISC technique may serve as a feasible short-term (about one to two years) alternative in patients with large acetabular defects, particularly in cases of PJI. Longer follow-up is necessary to establish the long-term survival of this technique.

O-arm-guided percutaneous microwave ablation and cementoplasty for the treatment of pelvic acetabulum bone metastasis

Objective

This study aims to evaluate the indications, safety, and efficacy of microwave ablation combined with cementoplasty under O-arm navigation for the treatment of painful pelvic bone metastasis.

Methods

We retrospectively collected data from 25 patients with acetabulum bone metastasis who underwent microwave ablation combined with cementoplasty. All patients underwent percutaneous microwave ablation combined with cementoplasty under O-arm navigation. The postoperative follow-up included evaluations of pain, quality of life, function, the incidence of bone cement leakage, and the presence of perioperative complications. Pain and quality of life were evaluated using the visual analog scale (VAS) and the QLQ-BM22 quality of life questionnaire for patients with bone metastases, respectively. The functional scores were calculated using the MSTS93 scoring system of the Bone and Soft Tissue Oncology Society.

Results

There were 10 males and 15 females with an average age of 52.5 ± 6.5 years, all 25 patients received percutaneous procedures, and no technical failure occurred. Major complications, including pulmonary embolism, vascular or nervous injury, hip joint cement leakage, and infection, were not observed in the current study. Pain regression was achieved in 24 of 25 patients. The mean VAS scores significantly decreased to 3.4 ± 1.0, 2.5 ± 1.2, and 1.2 ± 0.6 points at 1 week, 1 month, and 3 months after the procedure, respectively, compared with 7.0 points before the procedure (P < .05). The mean QLQ-BM22 score significantly decreased to 36.2 ± 4.9, 30 ± 5.6, and 25.4 ± 2.3 points at 1 week, 1 month, and 3 months after the procedure, respectively, compared with 55.8 points before the procedure (P < .05). The preoperative Musculoskeletal tumour society (MSTS) functional score of 25 patients was 18.5 ± 5.3 points, and MSTS score was 20.0 ± 3.0, 21.4 ± 4.9, and 22.8 ± 2.3 at 1 week, 1 month, and 3 months after the procedure, respectively (P < .05). The average bone cement injection volume was 8.8 ± 4.6 ml.

Conclusion

The use of O-arm-guided percutaneous microwave ablation combined with cementoplasty for the treatment of pelvic metastases could quickly and significantly alleviate local pain, prevent pathological fracture, and improve the quality of life of patients with reduced complications.

Outcomes of Hip Reconstruction for Metastatic Acetabular Lesions: A Scoping Review of the Literature

(1) Background: Management of metastatic periacetabular lesions remains a challenging area of orthopaedics. This study aims to evaluate and summarize the currently available reconstructive modalities, including their indications and outcomes. (2) Methods: A scoping review was carried out in accordance with PRISMA guidelines. Medline, EMBASE, and Cochrane were searched for relevant articles. (3) Results: A total of 18 papers met inclusion criteria encompassing 875 patients. The most common primary malignancy was breast (n = 230, 26.3%). Reconstruction modalities used were total hip arthroplasty (n = 432, 49.1%), the Harrington procedure (n = 374, 42.5%), modular hemipelvic endoprotheses (n = 63, 7.2%) and a reverse ice-cream cone prosthesis (n = 11, 1.25%). (4) Conclusions: Advances in implant design including use of dual mobility or flanged cups, tantalum implants, and modular hemipelvic endoprostheses allow for larger acetabular defects to be addressed with improved patient outcomes. This armamentarium of reconstruction options allows for tailoring of the procedure performed depending on patient factors and extent of periacetabular disease.

The Harrington Plus Reconstruction for Pelvic and Acetabular Metastases

•

The Harrington Plus reconstruction is a modification of the original Harrington rod technique for reconstruction of extensive periacetabular metastases. This procedure was developed in our institution.

•

An intrapelvic suprapectineal plate is used, with the aim of reconstructing a disrupted anterior column and reducing the risk of failure in cases where there is extensive medial bone loss.

•

This paper describes the outcomes of patients who have undergone this procedure to date.

Background

Surgical management of periacetabular bone metastases is challenging. The Harrington Plus reconstruction is a modification of the original Harrington rod technique. An intrapelvic suprapectineal plate is used, with the aim of reconstructing a disrupted anterior column and reducing the risk of failure in cases where there is extensive medial bone loss.

Methods

A retrospective review of the 13 patients who have undergone the Harrington Plus procedure to date was performed. Mobility status, EQ5D and Oxford Hip scores were assessed.

Results

There was a significant improvement in mobility status, EQ5D and Oxford Hip Scores at 6 months postoperatively (p < 0.05). Two patients returned to theatre for debridement of infection. There were no postoperative dislocations, cup medialisation or cases of loosening of the prosthesis. No patient required revision arthroplasty surgery.

Conclusion

The Harrington Plus procedure produces a reliable construct that allows patients with extensive periacetabular metastatic defects to fully weight-bear. Careful patient selection and multidisciplinary management is essential.

A Review and Description of Acetabular Impaction Bone Grafting: Updating the Traditional Technique

Restoring acetabular bone loss in revision hip arthroplasty is a major challenge for the orthopaedic surgeon. This paper discusses the traditional cemented technique of impaction bone grafting as applied to the acetabulum, as well as the evolution of the technique to employ uncemented implants. Some of the recent published literature regarding these techniques is reviewed and the personal experiences of the senior author with these techniques are also reported.

Pelvis weight-bearing ability after minimally invasive stabilizations for periacetabular lesion

Periacetabular metastatic lesions cause debilitating weight-bearing pain and pose a risk of pelvic pathologic fracture. Minimally invasive percutaneous stabilization is an alternative palliative therapy over extensive open reconstructive surgeries. This study aimed to investigate the biomechanical behaviors of three distinct techniques of percutaneous periacetabular stabilization. A total of 20 composite hemipelves custom-made to contain Harrington type III periacetabular lesion based on a patient's computed tomograpy scans were assigned to treatment groups of cementoplasty alone using polymethyl methacrylate (Cement), screw fixation alone using ischial and posterior-to-anterior screws (Screws), cement-augmented screws (Screws&Cement), and a control group (Untreated). All hemipelves were loaded in a mechanical test configuration mimicking a single-legged stance, and failure load, failure deformation, and construct stiffness were determined. In the experiments, Screws&Cement demonstrated the highest yield strength (4711 ± 362 N) and was 12% higher than Cement (4005 ± 304 N, p = 0.019), 125% higher than Screws (2097 ± 359 N, p < 0.0001), and 184% higher than Untreated (1658 ± 254 N, p < 0.0001). No significant difference in yield strength was found between Screws and Untreated. Screws&Cement also demonstrated the highest stiffness (1013 ± 92 N/mm), followed by Cement (893 ± 49 N/mm), and both groups were significantly stiffer than Screws (543 ± 114 N/mm, p < 0.0001) and Untreated (580 ± 91 N/mm, p < 0.0001 for Screws&Cement, and p = 0.0003 for Cement). This study demonstrated that a cement-augmented periacetabular reconstruction is an effective option for percutaneous treatment of Harrington III periacetabular metastatic lesion. The addition of pelvic screws over cementoplasty significantly improved the pelvis load-bearing strength. When large periacetabular lesions are present, augmented screw fixation appears to be the superior choice of treatment.

A novel and secure technique of stemmed acetabular cup implantation in complex hip reconstructions: a comparative study and technical note

PURPOSE

The stemmed acetabular cup (SAC) can be considered in several complicated situations. This type of prosthesis uses the iliac isthmus, which is most often preserved, thus allowing solid anchorage. Its implantation is prone to mechanical complications intraoperatively, such as extra-isthmic effraction, fracture, and early aseptic loosening. The aim of our study was to compare a new technique using a flexible motorized reamer combined with isthmus catheterization (Group A) versus the standard technique deploying a rigid reamer alone (Group B).

MATERIALS AND METHODS

A retrospective analysis was carried out of the SACs implanted at our hospital. The main evaluation criterion was visualization of extra-isthmic effraction (EIE) of the stem.

RESULTS

Fifty-six SACs (Integra Lepine®, Genay, France) were implanted, 31 in group A and 25 in group B. The mean follow-up was 21.6 months ± 22.3. This study found fewer EIEs using a flexible motorized reamer (0 versus 5, p = 0.014), less perioperative bleeding (p = 0.054), and less aseptic loosening in group A (p = 0.034). There was no difference in terms of infection or other mechanical complications post-operatively between the two groups.

CONCLUSION

Using iliac catheterization combined with a flexible motorized reamer when implanting a SAC helps to avoid EIE and it also appears to reduce complications such as peri-operative bleeding and early aseptic loosening. We recommend use of this surgical technique rather than a rigid reamer alone, and this new technique should allow widespread and more accessible use of this specific type of implant.

Acetabular reconstruction in oncological surgery: A systematic review and meta-analysis of implant survivorship and patient outcomes

BACKGROUND

Reconstruction of the hip for peri-acetabular oncological disease remains a challenge. The objective of this study was to summarize the evidence and identify techniques utilized for primary and metastatic tumors of the acetabulum and hemipelvis.

METHODS

A systematic review of the published literature was carried out in accordance with PRISMA guidelines. MEDLINE, EMBASE and Cochrane databases identified relevant articles. Quality was assessed using the Newcastle-Ottawa Scale. The study was registered on PROSPERO.

RESULTS

53 papers were included, 16 were suitable for meta-analysis. 909 patients had primary and 1140 metastatic disease. 1094 patients underwent reconstruction with conventional total hip arthroplasty (with or without cup-cage or cement augmentation) or modifications of the Harrington procedure, collectively termed 'non-complex'. 928 patients underwent 'complex' reconstructions with either a modular hemipelvic, saddle, reverse snow-cone, custom-made or 3D-printed endoprosthesis. The most common complication was deep infection (11%) followed by dislocation (5%). Mean MSTS scores were 61.9% for 'non-complex' versus 63.2% for 'complex' reconstruction. Meta-analysis suggested increased mortality for primary (OR 3.14; 95% CI 1.15-8.54) and trends toward reduced mortality for metastatic disease (OR 0.93; 95% CI 0.26-3.29) following 'complex' versus 'non-complex' reconstruction. Reoperation rates were higher following 'complex' reconstruction for metastatic disease (OR 1.90; 95% CI 0.66-5.46) and similar for primary disease (OR 0.98; 95% CI 0.45-2.14).

CONCLUSIONS

Peri-acetabular tumors are associated with high rates of morbidity and mortality. Decisions regarding implant selection are multi-factorial with recent increase in the use of custom-made and 3D-printing technologies. Multiple factors contribute to the oncological outcome and patient function. Further research is required in order to guide optimal practice.

Pelvic reconstruction using an ice-cream cone prosthesis: correlation between the inserted length of the coned stem and surgical outcome

BACKGROUND

Acetabular reconstruction using an ice-cream cone prosthesis has been a reliable reconstruction option following pelvic tumour resection. However, it remains unknown which factor determines the success of this procedure. We aimed to determine risk factors for complications and functional loss in acetabular reconstruction using an ice-cream cone prosthesis.

PATIENTS AND METHODS

Fifty-four patients with malignant bone tumours who underwent acetabular reconstruction using an ice-cream cone prosthesis between 2004 and 2016 were studied. The bone-stem ratio was calculated as the ratio of the inserted length into the bone per the entire stem length.

RESULTS

A total of 26 (48%) patients had at least one complication and 11 patients (20%) required surgical interventions. The complication rates were 71% and 40% with a bone-stem ratio ≤ 50% and > 50%, respectively (p = 0.026), and the bone-stem ratio significantly stratified the risk of complications (≤ 50%: OR, 4.67 versus > 50%; p = 0.048). The mean MSTS score at the final follow-up was 60% (range 23-97%): the scores were significantly lower in patients with complications/leg-length discrepancy (52%) than in those without (79%; p = 0.002). The mean score with a bone-stem ratio ≤ 50% was significantly lower than the score with a ratio > 50%, especially in patients who underwent non-navigated reconstructions (33% versus 64%; p = 0.001).

CONCLUSION

The inserted length of the coned stem into residual bone was predictive of complications and functional outcome. Surgical indication for this procedure should be considered with the size of the remaining ilium to stabilise the prosthesis with a coned stem longer than half length.

Surgical Treatment and Proposed Modified Classification for Harrington Class III Periacetabular Metastases

Objectives

This study aims to: (i) evaluate the outcome of patients with Harrington class III lesions who were treated according to Harrington classification; (ii) propose a modified surgical classification for Harrington class III lesions; and (iii) assess the efficiency of the proposed modified classification.

Methods

This study composes two phases. During phase 1 (2006 to 2011), the clinical data of 16 patients with Harrington class III lesions who were treated by intralesional excision followed by reconstruction of antegrade/retrograde Steinmann pins/screws with cemented total hip arthroplasty (Harrington/modified Harrington procedure) were retrospectively reviewed and further analyzed synthetically to design a modified surgical classification system. In phase 2 (2013 to 2019), 62 patients with Harrington class III lesions were classified and surgically treated according to our modified classification. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) 93 scoring system. The outcome of local control was described using 2‐year recurrence‐free survival (RFS). Owing to the limited sample size, we considered P < 0.1 as significant.

Results

In phase 1, the mean surgical time was 273.1 (180 to 390) min and the mean intraoperative hemorrhage was 2425.0 (400.0 to 8000.0) mL, respectively. The mean follow‐up time was 18.5 (2 to 54) months. Recurrence was found in 4 patients and the 2‐year RFS rate was 62.4% (95% confidence interval [CI] 31.6% to 93.2%). The mean postoperative MSTS93 score was 56.5% (20% to 90%). Based on the periacetabular bone destruction, we categorized the lesions into two subgroups: with the bone destruction distal to or around the inferior border of the sacroiliac joint (IIIa) and the bone destruction extended proximal to inferior border of the sacroiliac joint (IIIb). Six patients with IIIb lesions had significant prolonged surgical time (313.3 vs 249.0 min, P = 0.022), massive intraoperative hemorrhage (3533.3 vs 1760.0 mL, P = 0.093), poor functional outcome (46.7% vs 62.3%, P = 0.093), and unfavorable local control (31.3% vs 80.0%, P = 0.037) compared to the 10 patients with IIIa lesions. We then modified the surgical strategy for two subgroup of class III lesions: Harrington/modified Harrington procedure for IIIa lesions and en bloc resection followed by modular hemipelvic endoprosthesis replacement for IIIb lesions. Using the proposed modified surgical classification, 62 patients in the phase 2 study demonstrated improved surgical time (245.3 min, P = 0.086), intraoperative hemorrhage (1466.0 mL, P = 0.092), postoperative MSTS 93 scores (65.3%, P = 0.067), and 2‐year RFS rate (91.3%, P = 0.002) during a mean follow‐up time of 19.9 (1 to 60) months compared to those in the phase 1 study.

Conclusion

The Harrington surgical classification is insufficient for class III lesions. We proposed modification of the classification for Harrington class III lesions by adding two subgroups and corresponding surgical strategies according to the involvement of bone destruction. Our proposed modified classification showed significant improvement in functional outcome and local control, along with acceptable surgical complexity in surgical management for Harrington class III lesions.

Harrington rods for periacetabular pathological lesion: is it an option?

Advancement in cancer treatment has prolonged the survival of cancer patients; as a result, there are an increased number of patients with bone metastases and pathological fractures referred to orthopaedic surgeons for surgical intervention for a better quality of life. Metastasis around the hip joint can be painful and intervene with patients' daily activity, and reconstruction of the hip joint with periacetabular metastasis is complex and challenging especially longer cancer survivals might out-live their fixation. Several acetabular reconstruction techniques and implants have been described to overcome this problem; acetabular reconstruction and total hip arthroplasty still remains the standard surgical treatment, to relief pain and to improve function and quality of life. Harrington reconstruction of periacetabular metastatic disease combined with hip arthroplasty is one of the options that can address this clinical scenario safely; it is reproducible and cost-effective. In this review, we present case series of patients treated in our institution using Harrington rod technique for acetabular pathological lesions with good outcome.

A modified Harrington technique for periacetabular reconstruction in advanced metastatic bone disease and a discussion of alternative treatment options

Management of periacetabular lesions involves complex clinical decision making. The modified Harrington procedure with total hip arthroplasty can recreate pelvic stability with a cement rebar construct as well as a functional hip. This study analyzes the modified Harrington procedure to assess construct longevity and patient outcomes. We queried a prospectively maintained database to identify all patients at a large academic medical center from 2017 to 2019 with periacetabular metastatic disease treated with a modified Harrington. Medical records were reviewed and complications, patient outcomes, Musculoskeletal Society Tumor (MSTS) scores, and implant survival were recorded. A total of nine patients were treated with the modified Harrington between 2017 and 2019. At maximum follow- up there were zero revisions or longterm complications. The mean preoperative MSTS score was 2.2 (range, 0-18), compared to the mean postoperative MSTS score of 17.7 (range, 9-25) recorded at a mean 4 (range, 1-30) months following surgery (p<0.001). The modified Harrington technique total hip technique for reconstruction in periacetabular metastatic bone disease is a safe procedure with effective symptom relief, improvement in function, and excellent implant survivorship.

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.

Hip Arthroplasty Following Subtotal Sacrectomy for Chordoma

BACKGROUND/AIM

Chordomas often affect the sacrum with a high predilection for local-regional recurrence. Patients typically retain their ability to ambulate, and the development of metastatic disease in the periacetabular region can have significant morbidity and pain with ambulation. The purpose of the study was to describe the outcome of patients undergoing a hip arthroplasty following resection of a sacral chordoma.

PATIENTS AND METHODS

From 1990 to 2015, 84 patients underwent sacrectomy for chordoma, while four of these (5%) patients underwent hip arthroplasty. The most common level of nerve root sacrifice was S2-5 (n=2). The mean time between sacrectomy and hip arthroplasty was 7 years. Indications for arthroplasty included metastatic disease (n=3) and coxarthrosis (n=1).

RESULTS

Postoperatively two patients ambulated with a gait aid, and no patient had a Trendelenburg gait. The mean Harris Hip Score significantly improved from 49 to 80 postoperatively (p=0.02).

CONCLUSION

The results of this study indicate that hip arthroplasty is a durable treatment option for patients with metastatic disease or coxarthrosis following subtotal sacrectomy for chordoma.

Modified Harrington's procedure for periacetabular metastases in 89 cases: a reliable method for cancer patients with good functional outcome, especially with long expected survival

Background and purpose - The pelvis is the 3rd most common site of skeletal metastases. In some cases, periacetabular lesions require palliative surgical management. We investigated functional outcome, complications, and implant and patient survival after a modified Harrington's procedure.Patients and methods - This retrospective cohort study included 89 cases of surgically treated periacetabular metastases. All patients were treated with the modified Harrington's procedure including a restoration ring. Lesions were classified according to Harrington. Functional outcome was assessed by Harris Hip Score (HHS) and Oxford Hip Score (OHS). Postoperative complications, and implant and patient survival are reported.Results - The overall postoperative functional outcome was good to fair (OHS 37 and HHS 76). Sex, age, survival > 6 and 12 months, and diagnosis of the primary tumor affected functional outcome. Overall implant survival was 96% (95% Cl 88-100) at 1 year, 2 years, and 5 years; only 1 acetabular implant required revision. Median patient survival was 8 months (0-125). 10/89 patients had postoperative complications: 6 major complications, leading to revision surgery, and 4 minor complications.Interpretation - Our modified Harrington's procedure with a restoration ring to achieve stable fixation, constrained acetabular cup to prevent dislocation, and antegrade iliac screws to prevent cranial protrusion is a reliable reconstruction for periacetabular metastases and results in a good functional outcome in patients with prolonged survival. A standardized procedure and low complication rate encourage the use of this method for all Harrington class defects.

Percutaneous osteoplasty for the management of a pubic bone metastasis

Percutaneous osteoplasty (POP) has been proven to relieve pain due to osteolytic metastases by injecting bone cement to stabilize the pathological fracture. Nevertheless, there have been few reports about POP of metastases in the pubis. This article presents a case involving the use of POP to manage a metastasis in the pubis. After POP the patient experienced significant pain relief and improvement in the quality of life.

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.

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.

Potential accuracy of navigated K-wire guided supra-acetabular osteotomies in orthopedic surgery: a CT fluoroscopy cadaver study

BACKGROUND

The aim of this study was to evaluate the accuracy of supra-acetabular pelvic tumor resections in human, full-body cadavers and under realistic operation room conditions with the help of a navigation system and K-wires as guidance for the oscillating saw.

METHODS

Seven hemipelvises from fresh, human, male, full-body cadavers were used. A preoperative and a postoperative CT was performed. Under control of the navigation system K-wires were inserted and served as guidance for the oscillating saw to reduce the error by vibration and jerking movements. The accuracy of the computer aided resections was compared with the accuracy of freehand resections in customized 3D printed pelvises with geometries identical to the cadavers used.

RESULTS

The mean deviation of the navigated osteotomies was 1.9 mm (standard deviation 1.0 mm) significantly (P < 0.001) lower than the mean deviation of freehand osteotomies at 9.2 mm (standard deviation 3.7 mm).

CONCLUSION

Navigated K-wires for supra-acetabular osteotomies allow significantly higher accuracy than freehand procedures under simulated operation room conditions. Copyright © 2016 John Wiley & Sons, Ltd.

Synchronous double primary cancer - intrahepatic cholangiocarcinoma with bone metastases and thyroid carcinoma: A case report

There is a low incidence of multiple primary cancer, particularly when the cancer is synchronous. The present report presents a case of synchronous double primary malignancies. A 58-year-old woman was admitted to Ling Nan Hospital (Guangzhou, China) complaining of pain in the left hip. X-ray revealed an osteolytic lesion and further examination indicated the presence of double primary cancer, consisting of hepatic cholangiocarcinoma and thyroid carcinoma. Biopsy of the osteolytic lesion showed a metastatic adenocarcinoma of unknown origin. Subsequently, final diagnosis was confirmed by I-131 scan and liver lesion biopsy. The patient received positive multidisciplinary treatments and survived for 9 months following diagnosis. The results of the present case suggest that multiplicity of primary malignancy is not necessarily an indicator of poor prognosis, as long as effective diagnosis and adequate disease management are achieved.

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.