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TUMOUR Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 3  |  Page : 151-157
Reconstructive options in pelvic tumours


1 Department of Orthopaedics & Traumatology, Madras Medical College & Research Institute, Govt. General Hospital,Chennai, India
2 Surgical Oncologist, Govt. Royapettah Hospital, Chennai, India

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   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

How to cite this URL:
Mayilvahanan N, Bose J C. Reconstructive options in pelvic tumours. Indian J Orthop [serial online] 2005 [cited 2018 Dec 9];39:151-7. Available from: http://www.ijoonline.com/text.asp?2005/39/3/151/36702

   Introduction Top


Management of pelvic tumours is a challenging problem and the concept of limb salvage is a worthwhile alternative [1],[2] 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 [3] . 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 [4],[5] is another exigent task that is decided by multifarious factors.

The complex classification systems [4],[6] 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 Top


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 [7] . 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 [4],[6] . 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.

Nomenclature

(With reference to figure number 1 - Schematic diagram of Mayil & Bose Classification of Pelvic resections)

IL- Ilial segment

PA- Periacetabulum

PU- Pubis

PF- Proximal femur

SA- Sacrum

IL+PA. Ilial and peri-acetabular resection

IL+PA+PU. Entire hemi-pelvis is resected

Definition of Principles

Principle I - Pelvic resection




  1. A line drawn from the anterior inferior iliac spine to the sciatic notch demarcates the ilium (IL) from the periacetabulum (PA)
  2. 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)
  3. A line drawn vertically along sacroiliac joint demarcates the ilium (IL) from the sacrum (SA)
  4. When the complete segment of bone is resected it is indicated as IL, PA, PU.
  5. When only a part of the bone concerned is removed the letters denoting are slashed like IL, PA, PU.
  6. 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

  1. 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.
  2. 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

Or Rectum

Principle VII - Reconstruction done

R 0 No reconstruction

AR Arthrodesis

AL Allograft

PR Prosthetic reconstruction


   Results Top


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.

Complications

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%.

Oncological outcome

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

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[8] 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 Top


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 [4],[9],[10],[11],[12],[13] 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 [2],[10].

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 [24] who had also curetted the remaining lesions and administered post-operative irradiation in some patients.

The complication rates of Healey et al [15] (65%) and Campannacci and Capanna [16] (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 [17] .

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[19],[20],[21],[22]. Our series of 7 cases had good results in the earlier years [23],[24] .On long term follow up, the prostheses had higher rate of complications [25] . 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 [26] who used Dacron enveloped ceramic pelvic prosthesis for periacetabular tumours and acceptable outcomes in Gradinger's series [27] where a cementless adaptable prosthetic system was utilized or a combined prosthetic replacement [14] 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 [28] .

In our series, pseudoarthrosis after attempted arthrodesis [3],[29] 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 [1],[11], 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.

 
   References Top

1.Abudu A, Grimer RJ, Cannon SR, Carter SR, Sneath RS. Recon­struction of the hemipelvis after the excision of malignant tumours. J Bone Joint Surg (Br). (1997); 79: 773-779.  Back to cited text no. 1    
2. Capanna R, Donati D, Fazioli F, Martini A, Campanacci M. Il­iofemoral arthrodesis with intercalary allograft. In: Complications of limb salvage. prevention, management and outcome. Ed. Brown K. Montreal: ISOLS: 1991; 205 - 209.  Back to cited text no. 2    
3.O'Connor MI, Sim FH. Salvage of the Limb in the Treatment of Malignant Pelvic tumors. J Bone Joint Surg (Am). 1989; 71: 481-494.  Back to cited text no. 3    
4.Enneking WF, Dunham WK. Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg (Am). 1978; 60:731-746.  Back to cited text no. 4    
5.Harrington KD. Orthopaedic management of extremity and pelvic le­sions. Clin Orthop. 1995; 312; 136 - 147.  Back to cited text no. 5    
6.Dunham WK Jr. Acetabular resections for sarcoma. In; Enneking WF (ed) Limb Salvage in Musculoskeletal Oncology. Bristol-Myers/Zimmer Orthopaedic Symposium. New York: Churchill Livingstone. 1987; 170­186.  Back to cited text no. 6    
7.Enneking WF. A system of staging musculoskeletal neoplasms. Clin Orthop. 1986; 204: 9-24.  Back to cited text no. 7    
8.Enneking WF, Dunham W, Gebherdt MC, Malawer N, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumours of musculoskeletal system. Clin Orthop. 1993; 286: 241-246.  Back to cited text no. 8    
9.Aho Aj, Ekfors T, Dean PB, Aro HT, Ahonen A, Nikkanen V. Incorporation and clinical results of large allografts of the extremities and pelvis. Clin Orthop. 1994; 307:200-213.  Back to cited text no. 9    
10.Bell RS, Guest CB, Davis A, Langer F, Ling H, Gross AE, Czitrom A. Allograft reconstruction following periacetabular sarcoma resection In: Complications of limb salvage. prevention, management and out­ come. Edited by Brown K. Montreal: ISOLS. 1991; 219 - 222  Back to cited text no. 10    
11.Harrington KD. The use of hemipelvic allografts or autoclaved grafts for reconstruction after wide resection of malignant tumors of the pelvis J Bone Joint Surg (Am). 1992; 74: 331-341  Back to cited text no. 11    
12.Mnaymneh W, Malinin T, Mnaymneh LG, Robinson D. Pelvic al­lograft. A case report with a follow-up evaluation of 5.5 years. Clin Orthop. 1990; 255:128-132.  Back to cited text no. 12    
13.Pant R, Moreau P, Ilyas I, Paramasivan ON, Younge D. Pelvic limb­salvage surgery for malignant tumors. Int Orthop (SICOT). 2001; 24: 311-315.  Back to cited text no. 13    
14.Sanjay BKS, Frassica FJ, Frassica DA, Unni KK, McLeod RA, Sim FH. Treatment of giant-cell tumor of the pelvis. J Bone Joint Surg (Am). 1993; 74: 1466-1475.  Back to cited text no. 14    
15.Healey JH, Lane JM, Marcove RC, Duane K, Otis JC. Resection and reconstruction of periacetabular malignant and aggressive tumors. In New developments for limb salvage in musculoskeletal tumors. Edited by Yamamuro T. New York: Springer -Verlag. 1989; 443 - 450.  Back to cited text no. 15    
16.Campanacci M, Capanna R. Pelvic resection - The Rizzoli Institute experience. Orthop Clin North Am. 1991; 22:65-86.  Back to cited text no. 16    
17.Shin KH, Rougraff BT, Simon MA. Oncological outcomes of primary bone sarcomas of the pelvis. Clin Orthop. 1994; 304: 207 - 217.  Back to cited text no. 17    
18.Sawaguchi T, Tomita K, Setsuji A, Nomura S. Reconstruction after resection of pelvic bone tumors. In New developments for limb salvage in musculoskeletal tumors. Edited by Yamamuro T. New York: Springer -Verlag. 1989; 469-473.  Back to cited text no. 18    
19.Natarajan MV, Bose JC, Mazhavan V, Rajagopal TS, Selvam K. The Saddle prosthesis in periacetabular tumours. Int Orthop. 2001; 25:107­109  Back to cited text no. 19    
20.Muelemeester FD, Taminiau AHM. Saddle prosthesis after resection of a para-acetabular chondrosarcoma. Acta Orthop Scand. 1989; 60:363 - 364.  Back to cited text no. 20    
21.Mutscheler W, Burri C, Kiefer H. Functional results after pelvic re­section with endoprosthetic replacement. In: Limb salvage in muscu­loskeletal oncology. Edited by Enneking WF. New York: Churchill Livingstone. 1987; 156-166.  Back to cited text no. 21    
22.Nieder E, Keller A. The saddle prosthesis Mark II, Endo Model. In New developments for limb salvage in musculoskeletal tumors. Edited by Yamamuro T. New York: Springer -Verlag. 1989; 481-490.  Back to cited text no. 22    
23.Aboulafia AJ, Buch R, Mathew J, Li W. Malawar MM. Reconstruc­tion using the saddle prosthesis following excision of primary and meta­static periacetabular tumors. Clin Orthop. 1995; 314: 203 - 213  Back to cited text no. 23    
24.Sneath RS, Carter SR, Grimer RJ. Hemipelvic endoprosthetic re­ placement. In Limb Salvage. Major reconstructions in Oncological and Non tumoral Condition. Edited by Langlais F and Tomeno B. Berlin: Springer-Verlag. 1991; 379-384.  Back to cited text no. 24    
25.Van Loon CJM, Veth RPH, Pruszcynski M, Wobbes T, Lemmens JAM, Van Horn J. Chondrosarcoma of bone: oncological and functional results. J Surg Oncol. 1994; 57:214-221.  Back to cited text no. 25    
26.Shinjo K, Asai T, Saito S, Miyake N, Furusawa H, Kondo K, Tuboi S. Dacron fabric-enveloped alumina ceramic pelvic prosthesis for cementless reconstruction of periacetabular tumor defects. In: Compli­cations of limb salvage. prevention, management and outcome. Edited by Brown K. Montreal: ISOLS: 1991; 235 - 239.  Back to cited text no. 26    
27.Gradinger R, Rechl H, Hipp E. Pelvic Osteosarcoma. Resection, reconstruction, local control and survival statistics, Clin Orthop. 1991; 270: 149-158.  Back to cited text no. 27    
28.Langlais F, Vielpieu C. Allografts of the hemipelvis after tumor resec­tion. Technical aspects of 4 cases. J Bone Joint Surg (Br). 1989; 71: 58­62  Back to cited text no. 28    
29.Capanna R, Guernelli N, Ruggieri P, Biagini R, Toni A, Picci P and Campanacci M. Periacetabular pelvic resections. In: Limb salvage in musculoskeletal oncology. Edited by Enneking WF. New York: Churchill Livingstone. 1987; 141-146.  Back to cited text no. 29    

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N Mayilvahanan
4, Lakshmi Street, Kilpauk,Chennai - 600 010
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.36702

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    Figures

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