Reconstruction of the hip after resection of periacetabular oncological lesions: a systematic review.

AIMS: Reconstruction of the acetabulum after resection of a periacetabular malignancy is technically challenging and many different techniques have been used with varying success. Our aim was to prepare a systematic review of the literature dealing with these techniques in order to clarify the management, the rate of complications and the outcomes. PATIENTS AND METHODS: A search of PubMed and MEDLINE was conducted for English language articles published between January 1990 and February 2017 with combinations of key search terms to identify studies dealing with periacetabular resection with reconstruction in patients with a malignancy. Studies in English that reported radiographic or clinical outcomes were included. Data collected from each study included: the number and type of reconstructions, the pathological diagnosis of the lesions, the mean age and follow-up, gender distribution, implant survivorship, complications, functional outcome, and mortality. The results from individual studies were combined for the general analysis, and then grouped according to the type of reconstruction. RESULTS: A total of 57 studies met the inclusion criteria and included 1700 patients. Most lesions were metastatic (41%), followed by chondrosarcoma (29%), osteosarcoma (10%), Ewing's sarcoma (7%), and multiple myeloma (2%). The techniques of reconstruction were divided into seven types for analysis: those involving a Harrington reconstruction, a saddle prosthesis, an allograft and allograft prosthesis composite, a pasteurised autograft, a porous tantalum implant, a custom-made prosthesis and a modular hemipelvic reconstruction. The rate of complications was 50%, with infection (14%) and instability (8%) being the most common. Mortality data were available for 1427 patients (84%); 50% had died of disease progression, 23% were alive with disease, and 27% had no evidence of disease at a mean follow-up of 3.4 years (0 to 34). CONCLUSION: Both the rate of complications and mortality are high following resection of oncological periacetabular lesions and reconstruction. Many types of reconstruction have been used with unique challenges and complications for each technique. Newer prostheses, including custom-made prostheses and porous tantalum implants and augments, have shown promising early functional and radiographic outcomes. Cite this article: Bone Joint J 2018;100-B(1 Supple A):22-30.

High sacrectomy for locally recurrent rectal cancer: Can long-term survival be achieved?

BACKGROUND: Locally recurrent rectal cancer involving the upper sacrum is generally considered a contra-indication to curative surgery. The aim of this study was to determine if a survival benefit was seen in patients undergoing high sacrectomy. METHODS: All patients with locally recurrent rectal cancer involving the sacrum above the 3rd sacral body between 1999 and 2007 were retrospectively reviewed. Kaplan-Meier survival analysis was performed. RESULTS: Nine patients were identified with a median age of 63 years. The proximal extent of sacral resection was through S2 (n = 6), S1 (n = 2), and L5-S1 (n = 1). All patients had R0 negative-margin resection. Median operative time was 13.7 hr, and median operative blood transfusion was 3.7 L. Thirty-day mortality was nil. Postoperative complications requiring surgical intervention occurred in three patients. Local re-recurrence in the pelvis occurred in one patient. The overall median survival was 31 months (range, 2-39 months). Three patients still alive are free of disease after 40, 76, and 101 months, respectively. Ultimately, all deaths were due to metastatic disease. CONCLUSIONS: High sacrectomy that achieves clear margins in patients with recurrent rectal cancer is safe and feasible. A majority will die of metastatic disease, but long-term survival may be possible in some patients.

Proximal femoral allograft-prosthesis composites in revision hip replacement: a 12-year follow-up study.

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique. At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).

Intercalary segmental reconstruction after bone tumor resection.

BACKGROUND/AIMS: Intercalary resection can be used for primary as well as metastatic tumors. Reconstruction options include vascularized fibula graft, interposition of an allograft, combination of vascularized fibula and allograft, segmental prosthesis, insertion of an extracorporally irradiated autograft, segmental transportation, either with external fixation or by using an intramedullary rod, intercalary scaffolds augmented with growth factors, and technical refinements for the resection of tumors located close to the growth plate. The purpose of this review is to discuss the indications, limitations and pitfalls of each of these techniques. METHODS: The PubMed database was searched for articles on intercalary reconstruction after bone tumor resection and for the different reconstruction options presented in this review. Additionally, cross-referencing was used to cover articles eventually undetected by the respective search strategies. The resulting articles were then reviewed with regard to the different techniques, outcomes and complications of the reconstruction options. RESULTS: With the advance of imaging techniques and the use of chemotherapy for malignant bone tumors, surgical techniques can be refined. There are many techniques for the reconstruction of large intercalary defects of long bones, with which the orthopedic oncologist needs to be familiar. General oncologic principles of achieving a wide margin still need to be respected. CONCLUSION: The techniques presented in this review will allow a better functional outcome of patients. It will continue to be important to carefully analyze each patient's situation and to adapt and individualize the method of reconstruction used.

Surgical approach to a large dumbbell-shaped pelvic lipoma extending through the obturator foramen.

Lipomas are the most commonly occurring mesenchymal tumors. We report a technique used to manage a patient with a large dumbbell-shaped pelvic lipoma passing through the obturator foramen. Using the combined expertise of an orthopedic and pelvic surgeon, successful and safe removal of this benign dumbbell-shaped pelvic lipoma was achieved.

Does the method of treatment affect the outcome in soft-tissue sarcomas of the adductor compartment?

We have investigated the significance of the method of treatment on the oncological and functional outcomes and on the complications in 184 patients with soft-tissue sarcomas of the adductor compartment managed at three international centres. The overall survival at five years was 65% and was related to the grade at diagnosis and the size of the tumour. There was no difference in overall survival between the three centres. There was, however, a significant difference in local control with a rate of 28% in Centre 1 compared with 10% in Centre 2 and 5% in Centre 3. The overall mean functional score using the Toronto Extremity Salvage Score in 70 patients was 77% but was significantly worse in patients with wound complications or high-grade tumours. The scores were not affected by the timing of radiotherapy or the use of muscle flaps. This large series of soft-tissue sarcomas of the adductor compartment has shown that factors influencing survival do not vary across the international boundaries studied, but that methods of treatment affect complications, local recurrence and function.

Intravascular extension of an osteosarcoma of the pubic bone into periprostatic venous plexus.

Pelvic osteosarcomas are uncommon but aggressive tumors that can invade the vascular system. We report a case of a 33-year-old man who presented with groin pain and was found to have a chondroblastic osteosarcoma invading the periprostatic venous plexus. Meticulous intraoperative exploration of the pelvis is necessary in such cases to resect tumor completely, thereby maximizing local control and preventing embolic complications.

Rotationplasty about the knee: surgical technique and anatomical considerations.

Rotationplasty is an intercalary resection of a bone segment with subsequent reconstruction of the lower limb by rotating it through an arc of 180 degrees. After rotation, the rotated ankle functions as a knee joint, thereby powering a custom-made below-knee prosthesis. Rotationplasty is a satisfactory treatment option in selected patients. A prerequisite for this type of surgery is an intact sciatic nerve. Rotationplasty is indicated for skeletally immature patients with a tumoral lesion about the knee (<8-10 years of age), for older patients with large lesions that are not candidates for limb salvage as an alternative to above-knee amputation, and as a salvage procedure for chronically infected prosthetic implants. Preoperative planning includes the prediction of the exact remaining bone growth, because the ipsilateral distal tibial epiphysis will not completely substitute for the growth deficit resulting from the resected distal femoral and proximal tibial epiphyses. Therefore, minimal over length of the ankle of the operated leg is retained. Technical details of the surgery are described with particular emphasis on anatomical considerations. It provides a durable and biologic reconstruction and allows patients to become good functional below-knee prosthesis users and allows participation in recreational activities and sports.

The kinematic rotating hinge prosthesis for complex knee arthroplasty.

Fifty-eight patients (69 knees) treated with the Kinematic Rotating Hinged knee prosthesis for complex primary and salvage revision total knee arthroplasty were followed up for an average of 75.2 months (range, 24-199 months). The indications for use of the Kinematic Rotating Hinged knee prosthesis included severe bone loss combined with ligamentous instability (30 knees), nonunion of a periprosthetic fracture (10 knees), an acute periprosthetic fracture (nine knees), severe collateral ligamentous instability (five knees), reimplantation for infection (six knees), nonunion of a supracondylar femoral fracture (four knees), congenital dislocation of the knee (three knees), and treatment of a severely comminuted distal femur (two knees). At the time of surgery, the average patient age was 72 years (range, 46-92 years). Preoperatively, knee extension averaged 4.94 degrees (range, 0 degrees-40 degrees) and flexion averaged 81 degrees (range, 15 degrees-125 degrees). At final followup, knee extension averaged 1.25 degrees (range, -5 degrees-25 degrees) and flexion averaged 94.2 degrees (range, 5 degrees-125 degrees). The preoperative Knee Society Knee score averaged 40.3 points (range, 2-93 points) and improved to 77 points (range, 33-99 points) at final followup. Complications were numerous: 23 (32%) patients experienced at least one complication and 12 (17%) patients had two or more complications. Deep periprosthetic infection was the most common complication (14.5%), followed by patellar complications (13%), and prosthetic component breakage (10%). During the period of this study, there were 15,798 primary and 2673 revision total knee arthroplasties done at the authors' institution. The patients receiving a Kinematic Rotating Hinged knee prosthesis represent a highly complex and small subset (0.37%) of the overall population having knee arthroplasty. Although the use of the Kinematic Rotating Hinged knee prosthesis for these limited indications has been useful for the authors, the incidence of complications and the poor outcome of these complications is disconcerting. Hinged total knee arthroplasty should be reserved for the final salvage option of the treatment options available when doing complex primary and salvage revision knee arthroplasties.

Chondrosarcoma of the pelvis. A review of sixty-four cases.

BACKGROUND: Treatment of pelvic chondrosarcoma is a difficult problem for the musculoskeletal oncologist. Poor rates of survival and high rates of local recurrence after surgical treatment have been reported in previous studies. The present study was designed to review the long-term oncologic and functional outcomes of surgical management in a large series of patients with pelvic chondrosarcoma who were treated at a single institution. METHODS: The cases of sixty-four patients with localized pelvic chondrosarcoma that had been surgically treated between 1975 and 1996 were reviewed retrospectively. The study was limited to patients who had received no previous treatment for chondrosarcoma. There were forty-one male and twenty-three female patients who had a mean age of forty-seven years (range, fifteen to eighty-eight years). The patients were followed for a minimum of three years or until death. The median duration of follow-up of the living patients was 140 months (range, thirty-nine to 295 months). RESULTS: Thirty-three of the sixty-four patients were first seen with grade-1 chondrosarcoma; twenty-three, with grade-2; one, with grade-3; and seven, with grade-4 (dedifferentiated chondrosarcoma). Thirteen patients had a hemipelvectomy to achieve local tumor control, whereas fifty-one patients underwent a limb-salvage procedure. Twelve patients (19%) had local recurrence, and eleven (17%) had distant metastases. At the time of the final follow-up, forty-four patients (69%) were alive without evidence of disease, thirteen (20%) had died of the disease, six (9%) had died of unrelated causes, and one (2%) was alive with disease. Less than a wide surgical margin correlated with local recurrence (p = 0.014). High-grade tumors correlated with poor overall survival (p < 0.001). All patients who had a limb-salvage procedure were able to walk at the time of the final follow-up, and they had a mean functional score of 77%, according to the system of the Musculoskeletal Tumor Society. CONCLUSIONS: Aggressive surgical resection of pelvic chondrosarcoma results in long-term survival of the majority of patients. There is a high correlation between tumor grade and overall or disease-free survival.

Treatment of aneurysmal bone cysts of the pelvis and sacrum.

BACKGROUND: Aneurysmal bone cysts are benign, non-neoplastic, highly vascular bone lesions. The purpose of this study was to describe the prevalence, the clinical presentation, and the recurrence rate of aneurysmal bone cysts of the pelvis and sacrum and to examine the diagnostic and therapeutic options and prognosis for patients with this condition. METHODS: Forty consecutive patients with an aneurysmal bone cyst of the pelvis and/or sacrum were treated from 1921 to 1996. Their medical records and radiographic and imaging studies were reviewed, and histological sections from the cysts were examined. Seventeen lesions were iliosacral, sixteen were acetabular, and seven were ischiopubic. Seven involved the hip joint, and two involved the sacroiliac joint. All twelve sacral lesions extended to more than one sacral segment and were associated with neurological signs and symptoms. Destructive acetabular lesions were associated with pathological fracture in five patients and with medial migration of the femoral head, hip subluxation, and hip dislocation in one patient each. The mean duration of follow-up was thirteen years (range, three to fifty-three years). RESULTS: Thirty-five patients who were initially treated for a primary lesion had surgical treatment (twenty-one had excision-curettage and fourteen had intralesional excision); two patients also had adjuvant radiation therapy. Of the thirty-five patients, five (14%) had a local recurrence noted less than eighteen months after the operation. Of five patients initially treated for a recurrent lesion, one had a local recurrence. At the latest follow-up examination, all forty patients were disease-free and twenty-eight (70%) were asymptomatic. There were two deep infections. CONCLUSION: Aneurysmal bone cysts of the pelvis and sacrum are usually aggressive lesions associated with substantial bone destruction, pathological fractures, and local recurrence. Current management recommendations include preoperative selective arterial embolization, excision-curettage, and bone-grafting.

Primary mixed tumor of bone.

Mixed tumors occur most commonly in major salivary glands. They may rarely appear in other sites, such as skin, breast, and lung. There have been rare reports of similar tumors occurring in bone. We report on a patient with a primary mixed tumor of bone. No other primary site has become apparent on follow-up of 5 years. Although mixed tumors detected by bone biopsy are likely to be metastatic, they may rarely represent primary bone neoplasms.

Ewing's sarcoma: presentation and management.

Great strides have been made in the diagnosis and treatment of patients with Ewing's sarcoma. With the advent of modern chemotherapy, the long-term survival has improved to approximately 70%. Standard treatment for local control of the primary lesion has, historically, been chemotherapy and radiation. Currently, surgical resection has become a more effective option in the multidisciplinary treatment of patients with this disease. These current concepts and developments in the presentation and management of Ewing's sarcoma are discussed.

Is radiotherapy important for low-grade soft tissue sarcoma of the extremity?

Radiotherapy and limb-preserving surgery has replaced amputation and compartmental resection for treatment of soft tissue sarcomas. However, the role of radiotherapy in low-grade tumors remains unclear. This study reviews the outcomes of 132 patients who received multimodality treatment for low-grade soft tissue sarcoma. Large primary tumors (> 5 cm) and the absence of radiotherapy correlated with local recurrence. Radiotherapy was most effective in patients operated on with marginal margins. Patients who were treated with wide surgical margins or had small tumors (< or =5 cm) showed no benefit with adjuvant radiotherapy. Size greater than 5 cm and local recurrence correlated with metastasis. Radiotherapy appears to be important in the management of low-grade soft tissue sarcoma. The principles of local treatment for low-grade soft tissue sarcoma should be the same as for high-grade tumors with a combination of surgery and adjuvant radiotherapy. In a subset of patients with small and widely excised tumors, consideration may be given to withholding radiotherapy. Local recurrence and metastasis from low-grade soft tissue sarcoma may occur as long as 1 decade after primary tumor resection. Long-term review of patients with low-grade tumors may be indicated.

Total knee arthroplasty after ipsilateral peripheral arterial bypass graft: acute arterial occlusion is a risk with or without tourniquet use.

A retrospective review was done of the total joint registry at the Mayo Clinic, Rochester, Minnesota, which contains the computerized records of 19,808 consecutive total knee arthroplasties (TKAs) including primary and revision that were performed from 1970 to 1997. From that database, 9 patients were found to have had a TKA after an ipsilateral peripheral arterial reconstruction. One patient had had bilateral peripheral arterial reconstruction followed by bilateral TKA, and 10 TKAs were reviewed. The medical records were reviewed retrospectively with particular attention given to the type of peripheral bypass surgery performed, the bypass graft source, the timing of the bypass surgery relative to TKA, the use of a tourniquet at the time of TKA, and the occurrence of complications after TKA. Of the 10 TKAs, 2 patients had acute arterial occlusion. One patient had a tourniquet, and the other patient did not. There was not a statistical correlation between graft type, tourniquet use, timing of surgery, postoperative anticoagulation, and occurrence of arterial occlusion. There is a marked risk of acute thrombosis of an ipsilateral arterial bypass graft after TKA that cannot be eliminated by performing the TKA without a tourniquet. Careful monitoring of the vascular status of the limb is required in the early postoperative period to detect arterial compromise. Should limb ischemia be suspected, an emergent vascular surgery consultation is required, and arterial flow to the lower extremity must be re-established.

Clinicopathologic features and treatment of postirradiation sarcoma of bone and soft tissue.

BACKGROUND AND OBJECTIVES: An analysis of the clinicopathologic features and treatment of patients with postirradiation sarcoma of bone and soft tissue was performed to guide modern evaluation and management. METHODS: A retrospective analysis of 135 sarcomas in 130 patients was performed. RESULTS: The mean age of the 130 patients was 48 years, and there was a female predominance because of irradiation for carcinomas of the breast and uterus. Indication for irradiation was a soft tissue lesion (such as lymphoma or breast cancer) in 58.5% of patients and a bone lesion (such as giant cell tumor or fibrous dysplasia) in 41.5%. The latent period (interval between irradiation and discovery of the sarcoma) ranged from 4-55 years (mean, 17 years). Of the lesions, 74% were stage IIB (high-grade extra-compartmental) and 24% were stage III (metastases). Ninety-four patients received their treatment at our institution. Of the 61 patients with resectable disease, 49 had amputations and 12 had limb salvage procedures. The 5-year cumulative survival rate was 68.2% for patients with peripheral (extremities, including proximal femur and hip) resectable lesions and 27.3% for patients with central (pelvis, head/neck, and ribs) resectable lesions. The local recurrence rate correlated with the surgical margin achieved: intralesional, 73%, marginal, 64%, and wide, 23%. CONCLUSIONS: The prognosis for patients with peripheral resectable postirradiation sarcomas is good if a wide surgical margin can be achieved. This group of patients should be treated aggressively because they have a new cancer.

Surgical management of desmoid tumors of the female pelvis.

BACKGROUND: Desmoid tumors are neoplasms characterized by proliferation of fibroblasts without cytologic features of malignancy. Although desmoid tumors are not uncommon, pelvic desmoid tumors are rare and therapeutically challenging. We describe the surgical management of seven patients with histologically confirmed desmoid tumors arising in the pelvis. STUDY DESIGN: All patients, six with primary and one with recurrent desmoid tumors of the female pelvis, were treated at Mayo Clinic Rochester between 1976 and 1997. The mean age of one African-American and six Caucasian patients was 29.8 years (range 17 to 59 years). No history of previous relevant pelvic trauma was identified; six patients experienced pelvic or leg pain (or both). All patients presented with isolated masses; five of seven were located left of the midline, generally involving the obturator internis or levator muscles (or both). The surgical approach was transabdominal, with a vaginal component in one patient. In addition to this retrospective review of these seven patients, literature addressing the management of desmoid tumors of the female pelvis is reviewed. RESULTS: Extirpative surgery necessitated resection of musculoskeletal, vascular, or adjacent soft tissue structures. Mean tumor diameter was 13.9cm (range 5 to 27 cm). Although the median recorded blood loss was 1,425mL, one patient who refused blood products died secondary to surgical hemorrhage. The median followup for the remaining evaluable patients was 57 months (range 13 to 249 months). Recurrent disease developed in 3 of 6 patients at 3, 11, and 13 months after surgical resection and was successfully managed with subsequent reoperations, with or without adjuvant radiotherapy. CONCLUSIONS: Although recent reports demonstrate selective regression of desmoid tumors with antiestrogen therapy, management of symptomatic pelvic desmoid tumors in young women may necessitate an operation. In our series, all primary and recurrent tumors were managed with resection of involved bone and other adjacent soft tissues. The role of adjunctive radiotherapy or hormonal therapy remains to be defined.

Large tumor endoprostheses and extracortical bone-bridging: 28 patients followed 10-20 years.

Aseptic loosening is a common cause of failure in large tumor endoprostheses. The concept of extracortical bone-bridging was developed to tackle the problem of loosening. New bone which forms across the junction of the bone-prosthesis junction is believed to improve fixation by controlling the transfer of stresses across the junction as well as by giving additional stability to the prosthesis. We present the long-term experience with this concept following major reconstruction after tumor and non-tumor conditions in 31 patients. The overall function was good for upper and lower limb prostheses. Most patients had extracortical bone bridging which was maintained for over 10 years. In 1/3 of patients this involved over 75% of the prosthetic circumference. Prosthetic survival was best with intercalary devices, followed by proximal femoral and distal femoral prostheses. Survival of prostheses in young active patients was similar to that reported in older patients undergoing primary joint replacement.

Dedifferentiated clear cell chondrosarcoma.

Dedifferentiation, a change in the histologic character and clinical behavior of a tumor to a more immature and aggressive one, occurs in approximately 11% of all chondrosarcomas. The original lesion is usually a low-grade chondrosarcoma. Clear cell chondrosarcoma is a rare cartilaginous tumor of low-grade malignancy with a preference for the ends of long bones. It is usually curable by resection. Recurrence commonly follows inadequate surgery, and metastases to lung, brain, and bones can develop. However, dedifferentiation has not yet been described in association with clear cell chondrosarcoma. Three patients are described who were initially diagnosed as having clear cell chondrosarcoma of the femur. Two were treated with en bloc resection for a clear cell chondrosarcoma. One of these had an undifferentiated sarcoma in a local recurrence after 6 years. In the second, metastasis of the clear cell chondrosarcoma developed 5(1/2) years after surgery; autopsy revealed undifferentiated sarcoma in the lung, heart, and lumbar spine. The third patient had dedifferentiated clear cell chondrosarcoma at the time of resection following the biopsy diagnosis of clear cell chondrosarcoma. All three died with metastatic disease. These three patients represent three different manifestations of dedifferentiation-at initial diagnosis, at recurrence, and at metastasis. To our knowledge, this is the first description of dedifferentiation occurring in clear cell chondrosarcoma.