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![Page 1: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/1.jpg)
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
![Page 2: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/2.jpg)
CTOS, Montreal, November 2004.
Introduction
• Resection of large pelvic bone tumours often results in– segmental pelvic defect
– pelvic discontinuity
– loss of acetabulum
![Page 3: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/3.jpg)
CTOS, Montreal, November 2004.
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
![Page 4: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/4.jpg)
CTOS, Montreal, November 2004.
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
![Page 5: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/5.jpg)
CTOS, Montreal, November 2004.
Two Groups
Hemipelvic graft Peri-acetabular graft
![Page 6: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/6.jpg)
CTOS, Montreal, November 2004.
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
![Page 7: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/7.jpg)
CTOS, Montreal, November 2004.
• 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
![Page 8: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/8.jpg)
CTOS, Montreal, November 2004.
• 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
![Page 9: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/9.jpg)
CTOS, Montreal, November 2004.
• 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
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CTOS, Montreal, November 2004.
• 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
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CTOS, Montreal, November 2004.
• Group 2– 5 patients– type II resection
• all were proximal femoral primary tumours requiring extra-articular peri-acetabular resection
• no nerve resections required
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CTOS, Montreal, November 2004.
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)
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CTOS, Montreal, November 2004.
Group 1 Group 2
osteosarcoma
9 2
chondrosarcoma dedifferentiated clear cell
6 1
1
1 Ewings
1
fibrosarcoma 1 leiomyosarcoma 1
Histology
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CTOS, Montreal, November 2004.
Group 1 Group 2
ANED 7 4
AWED 4 1
DOD 5 0
Deceased(not of disease)
3 0
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CTOS, Montreal, November 2004.
• 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
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Group 1 hemipelvic allograftfunctional outcomes
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CTOS, Montreal, November 2004.
– 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)
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CTOS, Montreal, November 2004.
– 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
![Page 19: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/19.jpg)
Group 2 periacetabular reconstruction functional
outcomes
![Page 20: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/20.jpg)
CTOS, Montreal, November 2004.
– 3 patients • no complications
– 2 patients• complications
– 1case - 1 dislocation
– 1 case - 3 dislocations + ? ant. acetabular wall allograft #
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CTOS, Montreal, November 2004.
– functional scores• TESS 78
• MSTS87 17/35
• MSTS93 64%
– time to scores• average 55 months
• range 12 - 120 months
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The good
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CTOS, Montreal, November 2004.
• 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
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CTOS, Montreal, November 2004.
• 53 yrs, male• 3 years post extra
articular resection prox femoral chondrosarcoma
• doing well• single cane
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The not so good
![Page 26: Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649f585503460f94c7d1cc/html5/thumbnails/26.jpg)
CTOS, Montreal, November 2004.
• 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
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The bad
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CTOS, Montreal, November 2004.
• 60 yrs, male• 5 yrs post type Is + II
+ III for chondrosarcoma
• wound necrosis, infection, antibiotic suppression, allograft fracture
• 2 crutches / wheelchair
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CTOS, Montreal, November 2004.
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
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CTOS, Montreal, November 2004.
• 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