Rehabilitation and functional outcomes for thoraco-omphalo-ischiopagus conjoined twins five years after separation: A case report

Conjoined twins are identical twins joined in utero and are a rare phenomenon. This report discusses a case of female thoraco-omphalo-ischiopagus tripus conjoined twins. The twins were separated at age two, and once medically stable, spent one month in inpatient rehabilitation to improve their sitting balance and gross motor skills. This was followed by outpatient physical therapy. The twins initially had customized ZipZac seats, which they were able to wheel independently. After six months of therapy, the girls began walking with posterior walkers and prostheses. The hemipelvectomy prosthesis included a customized thoracolumbosacral orthosis component and was directly attached to a non-articulated pylon. A manual-locking hip joint was added to accommodate sitting. An articulated ankle-foot orthosis was used for the intact leg. Care of formerly conjoined twins requires comprehensive care from a multidisciplinary team involving, but not limited to, a physiatrist, orthopaedic surgeon, physical therapist, and orthotist/prosthetist. Complex congenital limb deficiencies are often a major undertaking for the rehabilitation team as continuous treatment and management are needed throughout the patient's lifetime due to growth, development, and evolving physical demands. Anatomic variations must be examined on a case-by-case basis but often include limb deficiencies, orthopedic abnormalities, and organ comorbidities.

Custom designed and 3D-printed titanium pelvic implants for acetabular reconstruction after tumour resection

BACKGROUND

Reconstructive procedure following resection of large pelvic tumours around the hip joint remains a complex challenge.

METHODS

This study presents a retrospective case series of patients presenting with benign or malignant pelvic tumour for which an internal hemipelvectomy including the hip joint and subsequent reconstruction with a custom designed 3-dimensional printed titanium pelvic implant (3DPPI) has been performed between August 2013 and January 2018.

RESULTS

15 consecutive patients with a median age of 33.9 years (IQR 26.4-72.2) and a median BMI of 20.7 kg/m2 (IQR 19.0-33.3) were reviewed after median follow-up of 33.8 months (IQR 24.0-78.1). The majority of patients presented with a malignant tumour as their principal diagnosis (n = 13, 86.7%). The median surgical time was 5.5 hours (IQR 4.5-8.5) and median peri-operative blood loss was 5000 ml (IQR 2000-10000). The median MSTS score at follow-up was 63.3% (IQR 51.7-86.7%). The median NRS in rest was 0.0 (IQR 0.0-5.0), the median NRS during activity was 2.0 (IQR 0.5-7.0) and the median HOOS-PS was 76.6% (IQR 67.9-91.0). 4 patients had implant-specific complications (n = 4, 26.6%); 1 hip dislocation (Henderson type 1a), 3 structural complications (type 3a), 1 deep infection (type 4a) and 1 local tumour recurrence (type 5b). At follow-up, 4 out of 15 implants were classified as a failure, resulting in an implant survival rate of 73.3%.

CONCLUSIONS

Acceptable peri-operative outcomes, functional results, complication rates and short-term implant survival can be achieved in a cohort of complex patients undergoing 3DPPI reconstruction after hemipelvectomy including the acetabulum.

Outcomes and Complications of Pelvic Chondrosarcomas Treated Using Navigation Guidance and Multidisciplinary Approach: Is the Tumor Volume a Prognostic Factor?

(1) Background: Pelvic Chondrosarcomas (CS) have a poor prognosis. The grade is the most important survival predictor; other factors are periacetabular location and Dedifferentiated CS subtype. The aim of the study is to investigate a series of CS of the pelvis, to analyze the prognostic factors that affect outcomes and to demonstrate how the use of intraoperative navigation can reduce the complications without worse outcomes. (2) Methods: Retrospective study on 35 patients (21 M, 14 F), median age at surgery 54 years (IQR 41−65), with pelvic CS, treated with hemipelvectomy under navigation guidance. (3) Results: 30 high-grade CS and 5 low-grade CS; mean follow-up 51.4 months. There was a positive linear correlation between the tumor volume and the presence of local recurrence at follow-up. The mean survival time of patients with larger chondrosarcoma volume was lower, but not significantly so. Lower MSTS score was associated with significantly lower survival time (p < 0.001). (4) Conclusion: in this series overall survival, LR and distant metastasis were comparable with recent literature, while complication rate was lower compared to similar series without the use of navigation. There was a correlation between tumor volume and local recurrence rate but not with the presence of metastasis at follow up.

Preoperative arterial embolization and wound complications after resection of malignant bone tumor in the pelvis: a nationwide database study

BACKGROUND

Massive intraoperative blood loss is common in pelvic malignant bone tumor surgery, and preoperative arterial embolization may be used in selected cases. Preoperative arterial embolization reportedly increases wound complications in pelvic fracture surgery, but little evidence is available regarding pelvic bone tumor surgery.

METHODS

Using a Japanese nationwide database (Diagnosis Procedure Combination database), we searched for patients who underwent pelvic malignant bone tumor surgery between July 2010 and March 2018. The primary endpoint was wound complications, defined as any wound requiring re-operation, negative pressure wound therapy or both. Univariate analyses (the chi-squared test for categorical variables, the unpaired t-test for continuous variables) and multivariate logistic regression analyses were performed to examine the association between preoperative arterial embolization and wound complications.

RESULTS

Among the 266 eligible patients, 43 (16%, 43/266) underwent embolization and 69 (26%, 69/266) developed wound complications. In the univariate analyses, preoperative arterial embolization (P < 0.001), duration of anesthesia (P < 0.001), the volume of blood transfusion (P < 0.001) and duration of indwelling drain tube (P < 0.001) were associated with wound complications. In the multivariate logistic regression analysis, preoperative arterial embolization was significantly associated with wound complications (odds ratio, 3.92; 95% confidence interval, 1.80-8.56; P = 0.001).

CONCLUSIONS

Preoperative arterial embolization may be associated with increased wound complications after pelvic malignant tumor surgery.

Novel radical pelvectomy technique to treat chondrosarcoma in a large-breed dog

Surgical management of chondrosarcoma with hemipelvectomy is well described, but there have been no reports on extensive excision involving bilateral pubis and unilateral ischium. This report describes a novel pelvectomy technique for the treatment of chondrosarcoma in a large-breed dog. A 12-year-old Labrador Retriever presented for tenesmus due to a large, intra-pelvic mass which was confirmed on computed tomography (CT). Surgery involved removal of the entire left ischium and both pubic bones with preservation of both hind limbs. Histopathology confirmed the diagnosis of a high-grade chondrosarcoma with tumour-free margins of less than 3 mm. The dog recovered well following surgery and regained ambulation within 9 days. Four months postoperatively, the dog had no ongoing pain or tenesmus and only a mild gait abnormality in the left hind limb. Pelvectomy involving the entire pubis and unilateral ischium was well tolerated in a large-breed dog. This technique may offer a novel surgical option to treat neoplasia previously considered too extensive for complete excision.

Primary malignant bone tumours of spine and pelvis in children

PURPOSE

Axial malignant bone tumours are rare in children and adolescents, and their prognosis is still relatively poor due to non-specific symptoms, such as back or groin pain, which may result in late hospital presentation. Therefore, it is very important to raise awareness regarding this pathology.

METHODS

We performed a narrative review, including scientific publications published in English. We searched Medline and Google Scholar databases for information on the incidence and prognosis of axial malignant bone tumours in children and adolescents (< 18 years). Outcomes of different surgical management strategies and reconstruction options were assessed.

RESULTS

The incidence of primary malignant bone tumours before the age of 18 years is approximately five per one million population; around 25% of these tumours are located in the axial skeleton. With a five-year survival rate of 50%, tumours in an axial location (chest cage, spine, pelvis) are associated with a poorer prognosis than tumours in more peripheral locations. En bloc excision with clear margins has been shown to improve local control and overall survival, even though obtaining adequate surgical margins is difficult due to the close location of large neurovascular structures and other major organs. Spinal reconstruction options include instrumented fusion with allograft or expandable cage. Pelvic reconstruction is needed in internal hemipelvectomy, and the options include biological, endoprosthetic reconstructions, hip transposition, arthrodesis or creation of pseudoarthrosis and lumbopelvic instrumentation.

CONCLUSION

Early diagnosis, a timely adequate multidisciplinary management, appropriate en bloc excision, and reconstruction improve survival and quality of life in these patients.

LEVEL OF EVIDENCE

V.

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.

Intra-articular Partial Acetabular Resection and Allograft Reconstruction for Synovial Sarcoma

Introduction:

The aim of this case report is to present an option of reconstruction in tumors involving the posterior wall and column of the acetabulum with sparing of the anterior column and the weight-bearing dome.

Case Report:

We are reporting a case of a 25-year-old female with histopathologically proven synovial sarcoma involving the left inferior pubic ramus, ischium, and posterior wall of the acetabulum, along with a large soft-tissue extension in the posterior and medial thigh. Wide local excision involving partial acetabular resection and reconstruction using a femoral head allograft was carried out. The patient was allowed full weight-bearing mobilization after 6 weeks. At 3 months’ follow-up, the patient was able to walk without support and was able to do active straight leg raising. There were no radiological signs of joint degeneration at the 12-month follow-up.

Conclusion:

Reconstruction with non-articular femoral head allograft can be a viable alternative after resection of tumor involving acetabulum. This procedure is expected to support the hip joint and restore function in the short term and recreate bone stock for future arthroplasty if the need arises.

SURGICAL TREATMENT RESULTS IN PATIENTS WITH PELVIC BONE TUMORS IN CASES OF PREOPERATIVE 3D MODELING USE

The use of computer and magnetic-resonance therapy permits high accuracy visualization of tumor lesion zone in patients with pelvic bone tumors. More precise results concerning lesion zones before surgical intervention have been obtained in cases of 3D modeling use.

OBJECTIVE

improvement of surgical treatment results due to determination of the optimal level for pelvic bone resection.

MATERIALS AND METHODS

Cohort study was realized using 3D modeling based on computer tomography data applying the software packet RadiAnt DICOM Viewer with 3D Volume Rendering and the software packet «SolidWorks». Two patient groups were investigated: 1) 13 patients without preliminary preoperative 3D modeling (control group) and 2) 14 patients with modeling (main group). In both groups relapse-free survival and age-dependent survival were evaluated.

RESULTS AND DISCUSSION

Tumor relapses were found in 6 patients (46.15 %) of control group and in 5 patients (33.33 %) of the main group. No statistically significant difference between groups concerning relapse-free survival results was detected. In both groups, medians of relapse-free survival were not obtained, two-year long relapse-free survival reaching (53.8 ± 13.8) % and (66.7 ± 12.2) % in control and main groups, respectively. Analyzing the cor- relation between patients age and results obtained the authors demonstrated the two-year relapse-free survival to reach (47.4 ± 11.5) % and (88.9 ± 10.5) % in patients aged above 40 and below 40, respectively (p = 0,06).

CONCLUSION

Because of small sample sizes in both groups, the use of 3D modeling does not demonstrate any signif- icant difference regarding two-year relapse-free survival. However, there is a tendency for further progress. The search of approaches for improvement of the treatment results for pelvic bone tumor patients remains among the most important study problem in current orthopedics for tumor patients.

Abdominal Wall Reconstruction with a Free Fibula Flap after Internal Extended Hemipelvectomy

Major pelvic resections for malignant tumors are infrequent and have significant morbidity and mortality, for instance, incisional hernias are postoperative complications uncommonly reported probably because most cases are overshadowed by more serious complications. Reconstruction depends on the extent of the resection and overall prognosis of the patient. A case of a late complex hypogastric and femoral incisional hernia after extended hemipelvectomy for recurrent osteosarcoma treated with distal abdominal wall fixation into a free fibula flap is reported.

Intestinal Perforation by a Toothpick as Reason for Necrotizing Fasciitis

Necrotizing fasciitis is an uncommon but often fatal disease. Given the various causes of necrotizing fasciitis, we report a case of sigmoid colon perforation caused by a toothpick subsequently resulting in fulminant necrotizing fasciitis of the retroperitoneum and right thigh successfully treated by hemipelvectomy and Hartmann´s procedure.

Management of traumatic hemipelvectomy through ERAS pathway: A case report

RATIONALE

Traumatic hemipelvectomy is a rare but life-threatening injury that involves separation of the pelvic ring from pubic symphysis usually results from high energy trauma and associated with other injuries.

PATIENT CONCERN

In this report, we describe a case of traumatic hemipelvectomy, who presented in hemorrhagic shock associated with other injuries such as: right groin injury with limitation of passive movement of right hip and knee joint, left pelvic visceral protruded out, and wrapped by peritoneum, all of the vulva and anal tear, lumbar vertebrae transverse process fracture.

DIAGNOSES

Traumatic hemipelvectomy.

INTERVENTIONS

The patient was managed through enhanced recovery after surgery (ERAS) pathway with multidisciplinary coordination.

OUTCOMES

Patient was able to walk with prosthesis or crutch, with associated injuries managed appropriately. The course was complicated with hemorrhagic shock and infection which were dealt promptly, with good recovery.

LESSONS

In our case, the multimodal management through ERAS path has helped decrease stress level, decrease complication, decrease morbidity, decrease the length of stay in the hospital, and aid in faster recovery.

The importance of the rehabilitation program following an internal hemipelvectomy and reconstruction with limb salvage - gait analysis and outcomes: a case study

Background: Chondrosarcomas account for approximately 20% of bone sarcomas, with the most common site being the lower limb. Hemipelvectomies that involve hindquarter amputation have previously been the treatment of choice for pelvic tumors. However, with advances in chemotherapy, radiotherapy, imaging and surgical techniques more patients are now being treated with limb salvage surgery. The rehabilitation outcomes following an internal hemipelvectomy have not been well identified and there is currently little, if any, gait analysis data on rehabilitation following hemipelvectomy in limb salvage patients. Case description: A 53-year-old male underwent an internal hemipelvectomy with limb salvage followed by a 2-year rehabilitation program. The aim of this case study is to describe temporal and spatial parameters, metabolic energy expenditure and joint kinematics of a patient with an internal hemipelvectomy who underwent a wide excision of a chondrosarcoma followed by intensive rehabilitation. Outcomes: Walking speed (1.6 m/s), stride length (1.7 m), stride width (0.13 m) and good symmetry in step length (right 0.85 m and left data 0.80 m) and stance time (right 62% and left 59%) indicate a walking pattern similar to the asymptomatic able bodied. Oxygen consumption was 16.6 ml/kg/min and oxygen cost 0.17 ml/kg/m. Discussion: Following the intensive 2-year rehabilitation program this patient's gait pattern was similar to a control group with no statistically significant difference in the movement of the left and right knee and ankle joints. Some differences were identified against the control group in respect of the movement of the pelvis and hips, but this is partly to be expected. This case study highlights the functional outcomes that can be achieved following limb salvage surgery with intensive rehabilitation and a high level of motivation from the individual. Implications for rehabilitation Advancements in chemotherapy, imaging and surgical techniques have allowed more patients to be treated with internal hemipelvectomy. The rehabilitation outcomes following an internal hemipelvectomy have not been well identified and there is little gait analysis data. This case study highlights the functional outcomes that can be achieved following limb salvage surgery with intensive rehabilitation and motivation from the individual. Rehabilitation following internal hemipelvectomy should include goal setting, lymphoedema management, physiotherapy and an exercise program.

[Unusual presentation of pigmented villonodular synovitis of the hip joint: case report and review of the literature]

INTRODUCTION

Pigmented villonodular synovitis (PVNS) is a rare clinical entity with higher incidence in women (3:1) and an age of presentation between 20 and 40 years. The hip is a rare site of appearance, being involved in only 15% of all cases.

CASE REPORT

47-year-old male with 10 years of evolution characterized by a limited range of motion, pain associated with an increase in volume and shortening of the pelvic limb. Imaging studies showed destruction of the hip joint and extension to the pelvis. The histopathology report described pigmented villonodular synovitis. His final treatment was left hemipelvectomy.

DISCUSSION

The presentation of the diffuse pigmented villonodular synovitis of the hip has a lower incidence and a locally aggressive behavior. It is necessary to consider differential diagnoses that include malignant neoplasms. The standard treatment is surgical.

Three-dimensional printing and computer navigation assisted hemipelvectomy for en bloc resection of osteochondroma: A case report

RATIONALE

Three-dimensional (3D) printed templates can be designed to match an individual's anatomy, allowing surgeons to refine preoperative planning. In addition, the use of computer navigation (NAV) is gaining popularity to improve surgical accuracy in the resection of pelvic tumors. However, its use in combination with 3D printing to assist complex pelvic tumor resection has not been reported.

PATIENT CONCERNS

A 36-year-old man presented with left-sided pelvic pain and a fast-growing mass. He also complained of a 3-month history of radiating pain and numbness in the lower left extremity.

DIAGNOSES

A biopsy revealed an osteochondroma with malignant potential. This osteochondroma arises from the ilium and involves the sacrum and lower lumbar vertebrae.

INTERVENTIONS

Here, we describe a novel combined application of 3D printing and intraoperative NAV systems to guide hemipelvectomy for en-bloc resection of the osteochondroma. The 3D printed template is analyzed during surgical planning and guides the initial intraoperative bone work to improve surgical accuracy and efficiency, while a computer NAV system provides real-time imaging during the tumor removal to achieve adequate resection margins and minimize the likelihood of injury to adjacent critical structures.

OUTCOMES

The tumor mass and the invaded spinal structures were removed en bloc.

LESSONS

The combined application of 3D printing and computer NAV may be useful for tumor targeting and safe osteotomies in pelvic tumor surgery.

The pedicle screw-rod system is an acceptable method of reconstructive surgery after resection of sacroiliac joint tumours

Hemipelvic resections for primary bone tumours require reconstruction to restore weight bearing along anatomic axes. However, reconstruction of the pelvic arch remains a major surgical challenge because of the high rate of associated complications. We used the pedicle screw-rod system to reconstruct the pelvis, and the purpose of this investigation was to assess the oncology, functional outcome and complication rate following this procedure. The purpose of this study was to investigate the operative indications and technique of the pedicle screw-rod system in reconstruction of the stability of the sacroiliac joint after resection of sacroiliac joint tumours. The average MSTS (Musculoskeletal Tumour Society) score was 26.5 at either three months after surgery or at the latest follow-up. Seven patients had surgery-related complications, including wound dehiscence in one, infection in two, local necrosis in four (including infection in two), sciatic nerve palsy in one and pubic symphysis subluxation in one. There was no screw loosening or deep vein thrombosis occurring in this series. Using a pedicle screw-rod after resection of a sacroiliac joint tumour is an acceptable method of pelvic reconstruction because of its reduced risk of complications and satisfactory functional outcome, as well as its feasibility of reconstruction for type IV pelvis tumour resection without elaborate preoperative customisation.

Level of evidence: Level IV, therapeutic study.

Type 3 internal hemipelvectomy: a report of two cases

Type 3 internal hemipelvectomy involves resection of the pubis. We report on 2 patients who underwent type 3 internal hemipelvectomy. One patient developed a bladder hernia, tumour recurrence, and a pathological fracture of the proximal femur. These were resolved with external hemipelvectomy 7 months later. Another patient underwent additional fascia lata transplantation to prevent development of hernia. Both patients had a stress fracture in the contralateral posterior ilium mimicking bone metastasis.

Internal hemipelvectomy with reconstruction for primary pelvic neoplasm: a systematic review

BACKGROUND

Hemipelvectomy is a major operation with significant risks including infection, prosthesis failure and fracture. This systematic review was designed to review the functional outcomes, oncologic outcomes and complications in patients who received internal hemipelvectomy and pelvic reconstruction for primary pelvic tumour.

METHODS

Searches on MEDLINE, the Cochrane Library, Embase and Google Scholar were performed to locate studies involving patients receiving internal hemipelvectomy and pelvic reconstruction using a prosthesis, implant or bone graft. All studies were either prospective or retrospective observational studies published in English.

RESULTS

This systematic review included 12 studies from 1990 to 2011 involving 217 patients from 5 to 77 years of age who had received follow-up for a period from 3 weeks to 15 years. Among the 12 studies, the mortality rate, disease-free rate and incidence of local recurrence were 10-69.2, 23.1-90.0 and 9.1-41.7%, respectively. The post-operative Musculoskeletal Tumor Society (MSTS) functional score ranged from 50 to 70 in the more recent studies. Compared with prostheses and other implants, patients who received allografts had the highest post-operative function, as shown by their MSTS scores, but also had a greater incidence of post-operative infection. On the other hand, the prosthesis group was associated with the highest percentage of fracture and dislocations, as well as other significant complications.

CONCLUSION

This comprehensive review provided informative details regarding the goals, outcomes and complications associated with this procedure and underscored the need for further investigation into the various surgical approaches currently available.

Midurethral autologous fascial sling surgery with reconstruction of the lower abdominal wall using the tensor fascia lata muscle flap for post-hemipelvectomy stress urinary incontinence

Hemipelvectomy is surgery for pelvic bone neoplasms. In the case of pubic bone osteosarcoma, the distal end of the rectus abdominis muscle is severed from the pubic and ischium bones, and the pelvic floor muscles are resected en bloc with the bone, which leads to stress urinary incontinence. Cancer control is prioritized over complications, and stress urinary incontinence is generally disregarded. A 25-year-old woman presented with stress urinary incontinence. She had undergone a hemipelvectomy for left pubic bone osteosarcoma, and stress urinary incontinence appeared and persisted since the surgery. We carried out a reconstruction of the tissue deficit of the rectus abdominis using the tensor fascia lata muscle flap simultaneously with a midurethral autologous fascial sling anchoring to the tensor fascia lata flap. Stress incontinence was successfully improved without morbidity. This is the first reported case of midurethral suspension with reconstruction of the lower abdominal wall with the tensor fascia lata flap for post-hemipelvectomy stress urinary incontinence.

Management of traumatic hemipelvectomy: an institutional experience on four consecutive cases

BACKGROUND AND OBJECTIVE

The incidence of traumatic hemipelvectomy is rare, but it is a devastating injury. Recently, an increasing number of patients with traumatic hemipelvectomy are admitted to trauma centers alive due to improvements of the pre-hospital care. Successful management requires prompt recognition of the nature of this injury and meticulous surgical technique. We present our successful experiences on four cases of traumatic hemipelvectomy in the past nine years.

PATIENTS AND METHODS

Four cases with traumatic hemipelvectomy were admited to our hospital from June 21, 2002 to September 3, 2011. All injuries occurred due to vehicle accident and all patients were in a state of severe hypotension, with two of them having anal lacerations. These four cases were treated immediately with resuscitation, control of hemorrhage, early amputation, repeated debridement and closure of the wounds. An angiographic embolization was given to control hemorrhage in two of the cases preoperatively. One case underwent fecal diversion. Wound infection occurred in all of cases which was successfully controlled by repeated debridements, effective anti-biotic regimen, split-thickness skin grafts.

RESULTS

All four cases were saved successfully with well-healed wounds during follow up from 1 to 7 years. They were able to walk by themself using crutches.

CONCLUSION

Adhering to the surgery principles of damage control including appropriate resuscitation, hemorrhage control, coagulopathy correction and multiple debridements and closure of the wounds in reasonable period of time can save the life of cases suffering from severe pelvic ring injury.

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.