Gordon Beadel, MB ChB, FRACS Anthony Griffin, BSc Christian Ogilvie, MD Jay Wunder, MD, FRCSC
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Transcript of Gordon Beadel, MB ChB, FRACS Anthony Griffin, BSc Christian Ogilvie, MD Jay Wunder, MD, FRCSC
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
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
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
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
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
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
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
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
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
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)
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
CTOS, Montreal, November 2004.
Group 1 Group 2
ANED 7 4
AWED 4 1
DOD 5 0
Deceased(not of disease)
3 0
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
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)
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
CTOS, Montreal, November 2004.
– 3 patients • no complications
– 2 patients• complications
– 1case - 1 dislocation
– 1 case - 3 dislocations + ? ant. acetabular wall allograft #
CTOS, Montreal, November 2004.
– functional scores• TESS 78
• MSTS87 17/35
• MSTS93 64%
– time to scores• average 55 months
• range 12 - 120 months
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
CTOS, Montreal, November 2004.
• 53 yrs, male• 3 years post extra
articular resection prox femoral chondrosarcoma
• doing well• single cane
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
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
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