| Abstract|| |
Background: Pelvic tumours present a complex problem. It is difficult to choose between limb salvage and hemipelvectomy.
Method: Forty three patients of tumours of pelvis underwent limb salvage resection with reconstruction in 32 patients. The majority were chondrosarcomas (20 cases) followed by Ewing sarcoma. Stage II B was the most common stage in malignant lesions and all the seven benign lesions were aggressive (B3). Surgical margins achieved were wide in 31 and marginal in 12 cases. Ilium was involved in 51% of cases and periacetabular involvement was seen in 12 patients. The resections done were mostly of types I & II of Enneking's classification of pelvic resection. Arthrodesis was attempted in 24 patients. Customized Saddle prosthesis was used in seven patients and no reconstruction in 12 patients. Adjuvant chemotherapy was given to all high-grade malignant tumours, combined with radiotherapy in 7 patients.
Results: With a mean follow up of 48.5 months and one patient lost to follow up, the recurrence rate among the evaluated cases was 16.6%. Oncologically, 30 patients were continuously disease free with 7 local recurrences and 4 deaths due to disseminated disease and 2 patients died of other causes. During the initial years, satisfactory functional results were achieved with prosthetic replacement. Long-term functional result of 36 patients who were alive at the time of latest follow up was satisfactory in 75% who underwent arthrodesis and in those where no reconstruction was used. We also describe a method of new classification of pelvic resections that clarifies certain shortcomings of the previous systems of classification.
Conclusion: Selection of a procedure depends largely on the patient factors, the tumour grade, the resultant defect and the tissue factors. Resection with proper margins gives better functional and oncological results
Keywords: Pelvic Resection; Classification; Reconstruction; Outcomes; Complications.
|How to cite this article:|
Mayilvahanan N, Bose J C. Reconstructive options in pelvic tumours. Indian J Orthop 2005;39:151-7
| Introduction|| |
Management of pelvic tumours is a challenging problem and the concept of limb salvage is a worthwhile alternative , to external hemipelvectomy, providing an adequate clearance with a useful functioning extremity. If satisfactory margins can be achieved by the excision of a pelvic tumor, salvage of the limb is justified from both an oncological and a functional standpoint  . Though technically demanding, limb salvage is increasingly possible with advances in imaging technology, making accurate pre-operative assessment of the tumor extent that helps in deciding the extent of resection. Choosing the appropriate reconstructive option from the five categories of reconstruction procedures , is another exigent task that is decided by multifarious factors.
The complex classification systems , of pelvic resection are impractical, as the tumours do not confine to the bony pelvic segments. Tumour resections most often involve soft tissues and later functional outcomes very much depend on the extent of their resection. This has not been mentioned. Disruption of the pelvic ring and / or the line of weight bearing were not considered. Margin of resection and type of reconstruction have not been pointed out. Hence the existing classification systems remain complex and confusing for the interpreter.
We evaluate our experience, the complications encountered and the outcomes of limb salvage highlighting the functional outcome of reconstructive procedures performed after resection of aggressive and malignant pelvic tumours and also describe a new classification.
| Materials and methods|| |
Between the years 1990 and 2002, forty-three patients underwent limb-sparing pelvic resections. Eighteen patients were females and 25 were males; their age ranged from 11 years to 55 years with a maximum of 14 patients in the third decade. The follow up period ranged from 12 months to 159 months (Mean 48.5 months). Pre-operative staging was done using roentgenography, CT scan, Technetium bone scan and MRI. Angiography was done in four patients.
Diagnosis and Grade: Chondrosarcomas (21 cases) predominated the series followed by Ewing's sarcoma (6 patients); none of the sarcomas presented with metastasis. Rare presentations included a case of Paget's sarcoma and a case of haemangiopericytoma. The commonest stage that presented was II B [Table I] of the Enneking's staging system for musculo-skeletal tumours  . All four Giant cell tumours and three other benign lesions were of Stage B3.
Resection & Reconstruction: Bony resections were done as those classified by Enneking and Dunham , . Soft tissue resections were done appropriately depending on the extent and margin of resection, based on Mayil and Bose classification. Thirty-seven patients had periacetabular resections and the acetabulum was retained in the rest [Table - 2]. Wide oncological margins were achieved in high-grade lesions (31 patients) and marginal margins in all benign lesions (7), metastatic lesions (2) and low-grade or intracompartmental sarcomas (3 patients).
Of the 32 cases reconstructed [Table - 3], arthrodesis at various levels was attempted in 24 patients using routine orthopaedic implants [Figure - 3],[Figure - 4]. Seven patients underwent customised, cemented saddle prosthetic replacement, made of surgical stainless steel 316 L [Figure - 5]. Free fibular autograft was used to bridge the skeletal defect in two cases. Eleven patients did not undergo any reconstructive procedure [Figure - 6].
Neoadjuvant treatment was given for 11 patients of osteosarcoma and Ewing's sarcoma. Pre-operative chemotherapy was combined with pre-operative radiotherapy in 7 cases. One giant cell tumour and a case of haemangiopericytoma underwent resections after embolectomy.
Mayil and Bose classification: We have developed a classification of pelvic resections based on the anatomical segments resected, including the bony as well as soft tissue resections and the nomenclature is user friendly.
(With reference to figure number 1 - Schematic diagram of Mayil & Bose Classification of Pelvic resections)
IL- Ilial segment
PF- Proximal femur
IL+PA. Ilial and peri-acetabular resection
IL+PA+PU. Entire hemi-pelvis is resected
Definition of Principles
Principle I - Pelvic resection
- A line drawn from the anterior inferior iliac spine to the sciatic notch demarcates the ilium (IL) from the periacetabulum (PA)
- A line drawn from the pubic ramus at the lower border of the acetabulum to the ischial ramus divides the periacetabulum (PA) from the pubis (PU)
- A line drawn vertically along sacroiliac joint demarcates the ilium (IL) from the sacrum (SA)
- When the complete segment of bone is resected it is indicated as IL, PA, PU.
- When only a part of the bone concerned is removed the letters denoting are slashed like IL, PA, PU.
- Combined resections are indicated as follows
a. IL +PA : Ilial and partial periacetabular resection
b. IL + PA + PU : Entire hemipelvis is resected
Principle II - Sacrum
- Sacrum is vertically divided into two halves at the midline. Each half is further divided vertically into a quarter by a line passing through the sacral foraminae.
- Sacrum is divided horizontally into two segments by a line drawn through the inferior border of the 2nd sacral foraminae
SA - - Total Sacrectomy
SA/2 - - One half of sacrum excised sagittally
SA /4 - - One quarter of sacrum excised sagittally
SA - Part of sacrum below S 2 excised transversely (Horizontal slash)
Principle III - Pelvic ring
O When the line of weight bearing and the pelvic ring is intact
O When the line of weight bearing and the pelvic ring is disturbed, the letter is slashed. The site of slash denotes the level of disruption.
Principle IV - Extent of soft tissue excised
S 0 Soft tissue not excised
S 1 Ilio-psoas excised
S 2 Gluteals excised
S 3 Psoas and gluteals excised
Principle V - Margin achieved
W Wide excision
M Marginal excision
C Contaminated excision
Principle VI - Organ resected
Ob Bladder Ou Uterus
Principle VII - Reconstruction done
R 0 No reconstruction
PR Prosthetic reconstruction
| Results|| |
Patients were followed up monthly for the first six months, six monthly thereafter both clinically and radiographically. One patient of Ewing's sarcoma died of massive haemorrhage due to femoral artery blow out, in the early postoperative period and another patient died of myocardial infarction at 75 months of follow up.
Wound infection was seen in 6 cases, which resulted in removal of the pelvic saddle endoprosthesis in two patients and implant (wire) removal in one. The remaining three patients responded well to conservative management. The posterior gluteal flap necrosed in two and femoral arterial thrombosis complicated the post-operative period in one patient. Migration of the saddle endoprosthesis was a late complication observed in three patients amounting to a biological complication rate of 30%.
With one patient lost to follow up after 56 months, 30 patients had continuously disease free (CDF) follow up period. Four patients died of disease that included 2 cases of chondrosarcoma, one patient of metastatic renal cell carcinoma and a case of Ewing's sarcoma.
Local recurrences were met with in eight patients of which, resections (in 5 cases of chondrosarcoma) and radiotherapy (in a case of Ewing's sarcoma) rendered them with no evidence of disease at their latest follow up. One patient of metastatic renal cell carcinoma underwent marginal resection and saddle prosthetic replacement after preoperative chemotherapy and radiotherapy developed fatal distant metastasis and had a local recurrence at 7 months follow up. Distant metastases in the form of spinal or lung secondaries were observed at 7, 39 and 43 months after resection in three patients that proved fatal in all of them. Of the eleven patients who developed oncological complications, the majority of patients had had lesions confined to the ilium [Table - 3]. Radiotherapy increased our postoperative biological morbidity albeit achieving the desired oncological clearance. One case of free fibular autograft done after resection of a low-grade chondrosarcoma of the pubis had a poor outcome due to infection and local recurrence.
Functional outcome was studied in 36 patients who were either continuously disease free or had no evidence of disease at the time of latest follow up, using Enneking's evaluation system [Table - 4]. During the initial years, satisfactory results were achieved in patients who had prosthetic replacement and poor results in those who had no reconstruction because of instability. But excellent to good long-term results were obtained with solid fusion achieved in 6 of 21 patients or pseudoarthrosis after attempted arthrodesis in 10 of 21 patients and in 7 patients where no reconstruction was used. The overall functional result was excellent in 3 patients, good in 24 giving a satisfactory outcome in 75%. Five patients did poorly and 4 showed fair results.
| Discussion|| |
Resections of massive pelvic tumours can only be done by a combination of Enneking's resection types to achieve oncologically free surgical margins. A preoperative decision to reconstruct the defect that ensue resection may not always stand unmodified once the intraoperative conditions demand an alternative procedure. That which provides adequate stability and mobility in the long term, would be the near ideal option of reconstruction. The advantages and disadvantages of any reconstructive procedure are well known ,,,,, and the selection of a particular procedure depends largely on the patient factors, the tumour grade, the resultant defect and the tissue factors. Osteochondral allografts have high incidence of complications like infection, fracture, dislocation, and partial graft resorption and post-operative death with an overall poor result ,.
Resection of large bony defects, extensive soft tissue invasion, especially of the abductors of the hip does not favour any reconstructive methodology. Such patients have performed satisfactorily even without being subjected to any reconstructive procedure. Four patients of Giant cell tumour presented as massive aggressive (B3) lesions involving most of the hemipelvis, thinning out the pelvic cortex, that a routine intralesional excision and curettage with cementation was not feasible. Hence marginal resections were done that gave no recurrence of lesions in any of them comparable to Sanjay et al  who had also curetted the remaining lesions and administered post-operative irradiation in some patients.
The complication rates of Healey et al  (65%) and Campannacci and Capanna  (58%) are comparable with that of our series with an overall complication rate of 53%. Local recurrence rate of 19% of our series is comparable to that reported by Connor et al 3 with a similar correlation between the surgical margins achieved i.e., 3 of 12 patients with marginal resections and 5 of 30 patients with wide resections developed local recurrence. All five patients of our series, who underwent internal hemipelvectomy, were continuously disease free at the time of latest follow up. Still it is difficult to compare this oncological result with other pelvic resections as the diagnoses and the tumour grades differ  .
With regard to location of tumours [Table - 3], the clearance was inadequate in those involving the ilium alone and those over the ischial tuberosity and the sacrum 25 resulting in oncologically poor outcomes.
The use of Saddle prosthesis maintains limb length, allows early weight bearing without pain and achieves good functional results with a stable and mobile articulation,,,. Our series of 7 cases had good results in the earlier years , .On long term follow up, the prostheses had higher rate of complications  . They tended to migrate in three and removal following infection in two patients gave fair and poor results despite good pseudarthrosis achieved by fibrosis. This is in contrast to those good results achieved by Shinjo  who used Dacron enveloped ceramic pelvic prosthesis for periacetabular tumours and acceptable outcomes in Gradinger's series  where a cementless adaptable prosthetic system was utilized or a combined prosthetic replacement  that gives fewer complications and better functional results. Preserving iliac crest as a pedicle graft and using large screws for fixation as reported by Langlais and Vielpier had satisfactory results  .
In our series, pseudoarthrosis after attempted arthrodesis , and patients with no reconstruction fared functionally well with less morbidity supported by tissue fibrosis and orthotic devices providing the necessary stability and compensation for shortening.
The reconstructive options for the functional defect that follows internal hemipelvectomy or continuity resections are many and require long-term follow up and standardization. With continuing emphasis on anatomical reconstruction by biological or mechanical means ,, the role of no reconstruction also needs due attention. Arthrodesis or flail hip provides a better option than other methods in view of long-term functional rehabilitation. Technical modifications of our customised cemented saddle prostheses would probably improve their performance in providing both mobility and stability in those patients who are oncologically free of disease. A comprehensive approach to this difficult area of pelvic reconstruction yields better functional and oncological results.
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Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]