Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction...

Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects

following tumour resection.

Gordon Beadel, MB ChB, FRACS

Anthony Griffin, BSc

Christian Ogilvie, MD

Jay Wunder, MD, FRCSC

Robert Bell, MD, FRCSC

Peter Ferguson, MD, FRCSC

Mt Sinai Hospital

Toronto, Ontario, Canada

CTOS, Montreal, November 2004.

Introduction

• Resection of large pelvic bone tumours often results in– segmental pelvic defect

– pelvic discontinuity

– loss of acetabulum


Several Options for Reconstruction

- allograft bone

• hemipelvic allograft

• smaller structural allograft

– vascularised bone graft

– reinsertion irradiated/autoclaved resection specimen

– hemipelvic prosthetic replacement

– saddle prosthesis

– Arthrodesis


Mount Sinai Hospital Approach

• it has been the practice of our unit to use allograft reconstruction combined with THA

• we have identified two distinct groups based on– technical difficulties of the

procedure

– complications

– long term outcome


Two Groups

Hemipelvic graft Peri-acetabular graft


Purpose & Method

Review functional and oncologic outcomes of these two groups

• local ethics committee approval obtained• retrospective review of our prospectively

collected database undertaken– database ongoing since 1989– all patients who had undergone combined

pelvic allograft and THA reconstruction for bone tumour were identified and included


• Anatomic tumour extent was described by Enneking & Dunham classification:– zone I: supra-acetabular ilium– zone II: peri-acetabular– zone III: ischium, inferior and superior

pubic rami


• Two patient groups were– Group 1

• Hemipelvic resection

• Zones I + II or Zones I + II

• + III

– Group 2• periacetabular resection

• Zone II

Group 1

Group 2


• Group 1– 19 patients

• 12 type I + II resections

• 7 type I + II + III resections

• included 11 cases requiring partial sacral resection

• 5 patients required nerve resection– sciatic nerve - 1 case

– nerve roots - 4 cases


• Group 1 reconstruction– 19 cases

• irradiated hemipelvic allograft and THA– all cemented acetabular implants

– proximal femoral replacement implant in 1 case

– mesh capsular reconstruction in 12 cases


• Group 2– 5 patients– type II resection

• all were proximal femoral primary tumours requiring extra-articular peri-acetabular resection

• no nerve resections required


Results

• minimum follow up 15 months– group 1: 17-167 months– group 2: 15-154 months

• average age– group 1: 41 years (16-64)– group 2: 42 years (31-50)


Group 1 Group 2

osteosarcoma

9 2

chondrosarcoma dedifferentiated clear cell

6 1

1

1 Ewings

1

fibrosarcoma 1 leiomyosarcoma 1

Histology


Group 1 Group 2

ANED 7 4

AWED 4 1

DOD 5 0

Deceased(not of disease)

3 0


• average surgical times• group 1 594 mins (450-728)• group 2 596 mins (510-704)

• returns to the OR– group 1 12 patients (63%)

• average 3.2 times (range 1 to 6)

– group 2 1 patient (20%)• 2 times

Group 1 hemipelvic allograftfunctional outcomes


– 7 patients (37%) allograft remained intact without infection

• 3 patients– revision THAs

» for allograft fractures and THA loosening

• average scores for these 7 patients– TESS 64

– MSTS87 17/35

– MSTS93 45%

– average time to score 52 months (3 - 120)


– 9 patients had deep infection (47%)– 1 patient 2° to unrelated peritoneal sepsis

• 3 patients maintained a functional implant with long term antibiotic suppression

– TESS 30 (22.2-37.5)– MSTS87 15/35 (12-17/35)– MSTS93 41% (33-50)– average time to scores 30 months (6-60)

• 1 patient– allograft removal

• 4 patients – hindquarter amputation

• 1 patient– allograft fragmentation in situ

Group 2 periacetabular reconstruction functional

outcomes


– 3 patients • no complications

– 2 patients• complications

– 1case - 1 dislocation

– 1 case - 3 dislocations + ? ant. acetabular wall allograft #


– functional scores• TESS 78

• MSTS87 17/35

• MSTS93 64%

– time to scores• average 55 months

• range 12 - 120 months

The good


• 47 yrs female• 15 years post type I +

II resection for chondrosarcoma

• Revision THA for acetabular loosening at 8 years

• doing well• walks with single cane


• 53 yrs, male• 3 years post extra

articular resection prox femoral chondrosarcoma

• doing well• single cane

The not so good


• 65 yrs, male• 9 yrs post type I + II +

III resection for chondrosarcoma

• chronic infection managed with suppressive antibiotics

• large inguinal hernia• uses 2 crutches

The bad


• 60 yrs, male• 5 yrs post type Is + II

+ III for chondrosarcoma

• wound necrosis, infection, antibiotic suppression, allograft fracture

• 2 crutches / wheelchair


Conclusions

• Composite hemipelvic allograft and THA reconstruction of massive pelvic defects– when successful (1/3 patients) provides a

reasonable level of function and a satisfactory outcome

– but is associated with high rates of major complications

• infection


• In comparison smaller structural allograft and THA composite reconstructions for type II acetabular resections– more predictable and have a better outcome– resulting in a good level of function– lower complication rate

Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction...

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