Arch Orthop Trauma Surg (2011) 131:1609–1615 DOI 10.1007/s00402-011-1359-5
ORTHOPAEDIC SURGERY
Reconstruction with modular hemipelvic prosthesis for the resection of solitary periacetabular metastasis Xiaodong Tang • Wei Guo • Tao Ji
Received: 12 April 2011 / Published online: 14 September 2011 Ó Springer-Verlag 2011
Abstract Background The outcomes of patients with solitary metastasis around the acetabulum who received en bloc resection and reconstruction are unclear. The purpose is to evaluate the oncologic results, complications, and functional outcomes in these patients. Methods Fifteen patients who underwent periacetabular resection and modular endoprosthetic reconstruction were reviewed retrospectively. Results Eleven patients were alive and four had died of their respective diseases. The mean follow-up time for the living patients and the non-surviving patients was 32 and 11 months, respectively. One of the three patients presented with local recurrence received hindquarter amputation. Five patients with superficial wound problem were treated with debridement and were healed eventually. Two patients who had hip dislocation received closed reduction. Pain was relieved in most patients, and ten patients were able to walk outside their house. The average MSTS 93 score was 20.9 of a total of 30 points (69.7%). When evaluated according to the modified Allan scoring system, postoperative scores on pain, independence, and mobility had significant improvement. Conclusion En bloc tumor resection and reconstruction with modular hemipelvic prosthesis in patients who had a solitary periacetabular metastasis can provide long-term survive, tumor local control, low complication rate, and good functional recovery.
X. Tang W. Guo (&) T. Ji Musculoskeletal Tumor Center, People’s Hospital, Peking University, Beijing 100044, China e-mail:
[email protected]
Keywords Neoplasm metastasis Acetabulum Endoprosthesis Surgery
Introduction Bone is a common site for metastatic carcinoma of the breast, lung, kidney, and prostate [1]. Surgical intervention is a proper choice for impending or actual pathologic fracture. Palliative intralesional curettage and internal fixation could achieve pain relief and functional recovery in most patients with multiple metastatic lesions, who had a short-term living period. For patients with a solitary bony metastasis who had a prolonged life expectancy, wide resection was reported with good clinical outcomes. In a study [2] of 25 patients with solitary bony metastasis from renal cell carcinoma which mainly involved long bones, radical resection was carried out, only one local recurrence occurred, and 54% of 3-year survival rate was achieved. Even in studies of patients with solitary metastasis on spine, local recurrence rate between 0 and 17% was reported with long-term survive after total en bloc spondylectomy [3, 4]. However, patients with only a single focus of metastasis around the acetabulum for whom en bloc resection for curative purpose is recommended [5–7] have unclear oncologic result. In a report [8] of 14 patients with en bloc resection for solitary bone metastases of the pelvis, although favorable results were obtained without the development of local recurrence, and six survivors had long-term survival with median of 74.5 months, only five patients had a periacetabulum lesion. While in other studies, both patients with solitary acetabular lesion and other multiple metastases received tumor curettage, and the result was not reported separately [9–11].
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Endoprosthetic replacement after wide resection may be appropriate for isolated metastasis in long bones with few complications and good functional recovery [12]. However, the reconstruction of acetabulum after aggressive resection is technically difficult. Harrington procedures [6] including cemented total hip arthroplasty augmented with revision acetabular components and threaded pins can be only adopted in patients with adequate periacetabular bony structure. Saddle prosthesis and custom-made pelvic prosthesis replacement in pelvic metastasis were both reported with a few complications and limited function [5, 7, 13, 14]. In a report [13] of reconstruction with saddle prosthesis for advanced metastatic lesions of the acetabulum, the complication rate was 20% and the average MSTS function score was 55%. In our institute, a newly designed modular hemipelvic prosthesis was used in recent years for periacetabular metastasis reconstruction [15]. This report presents our experience in en bloc tumor resection and reconstruction with modular hemipelvic prosthesis in patients who had a solitary periacetabular metastasis. We ask whether these aggressive surgical treatment could provide selected patients with: (1) longterm survive and tumor local control; (2) low complication rate; and (3) good functional recovery.
Arch Orthop Trauma Surg (2011) 131:1609–1615
Fig. 1 A preoperative plain radiograph shows destruction of the right acetabulum in a 43-year-old female patient with solitary periacetabular metastasis from renal cell carcinoma
Materials and methods This retrospective study was performed after obtaining the IRB approval. Between January 2002 and August 2009, 124 consecutive patients with pelvic metastases received surgical intervention in our institute. Medical records, including operative procedures, radiographs, pathological diagnosis, and follow-up information, were retrospectively reviewed for each patient. The inclusion criteria were as follows: (1) acetabular destruction of metastatic disease; (2) no other skeletal or visceral involvement; (3) effectively control the primary site; (4) en bloc resection of the tumor for curative purpose; and (5) reconstruction with a modular hemipelvic prosthesis. Patients who had multiple metastases or received Harrington procedures were excluded from the study. There were 15 patients included, 7 of whom were males and 8 were females. Patients ranged from 20 to 71 years of age with an average of 51 years. All 15 patients with modular hemipelvic prosthesis were followed up for a mean of 26 months (range 4–60 months). Preoperatively, all patients had complete imaging examinations on the pelvis (shown in Figs. 1, 2), including plain radiograph, computed tomography (CT), and magnetic resonance imaging (MRI). Eight patients had tumors greater than 10 cm in diameter. The tumor volume, which was calculated using the formula for a sphere [16], ranged from 89 to 1,166 cm3 with a mean of 697 cm3. Routinely,
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Fig. 2 T2-weighted magnetic resonance imaging shows involvement of acetabulum
patients also had a technetium99 bone scan of the entire skeleton, a plain radiograph of the chest, and an abdominal ultrasound to exclude multiple metastases. Five patients had additional PET CT scan for advanced confirmation. Ten patients who had no previous cancer diagnosis received percutaneous needle biopsy. The diagnoses of primary tumor included four renal cell carcinomas, three breast cancers, three unknown primary tumors, one melanoma, one lymphoma, and one patient each with lung, liver, and uterine cervix carcinoma (Table 1). No patients underwent radiotherapy of the pelvic metastasis as a palliative treatment preoperatively. Based on the classification of pelvic tumor resection described by Enneking and Dunham [17], three patients had Type II (periacetabular), five had Type I/II (periacetabular and ilium), four had Type II/III (periacetabular and pubis), and three had Type I/II/III (the whole hemipelvis) pelvic resection. The defect of acetabulum was reconstructed with a modular, titanium hemipelvic prosthesis (ChunLi Co,
20
57
55
45
47
61
43
21
69
70
60
71
55
55
38
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Male
Male
Female
Female
Female
Male
Male
Female
Female
Female
Female
Male
Male
Female
Male
Gender
Liver carcinoma
Unknown primary tumor
Breast cancer
Lung carcinoma
Lymphoma
Renal cell carcinoma
Renal cell carcinoma
Melanoma
Renal cell carcinoma
Breast cancer
Breast cancer
Unknown primary tumor
Renal cell carcinoma
Uterine cervix carcinoma
Unknown primary tumor
Primary tumor
484
992
1,166
1,152
89
544
292
1,125
473
1,080
345
249
633
900
416
Tumor size (cm3)
I/II
I/II
I/II/III
I/II
II
I/II
I/II
I/II/III
II/III
I/II/III
II/III
II/III
II/III
II
II
Resection type
Intralesional
Intralesional
Intralesional
Marginal
Wide
Marginal
Wide
Marginal
Wide
Intralesional
Marginal
Wide
Marginal
Marginal
Marginal
Margin size
1,200
3,100
1,000
4,200
800
2,000
1,600
1,200
1,800
1,200
1,000
3,500
2,000
1,200
2,500
Blood loss (mL)
200
280
220
300
240
180
210
200
250
255
220
325
265
330
300
Operative time (min)
19
20
22
25
29
33
34
6
35
36
39
60
19
4
14
Follow-up (month)
Local recurrence
None
None
None
None
None
None
None
None
Local recurrence
None
None
None
Local recurrence
None
Local recurrence
AWD
NED
NED
AWD
NED
NED
NED
DOD
NED
AWD
AWD
NED
DOD
DOD
DOD
Patient status
Oncologic outcome
NED no evidence of disease, DOD died of disease, AWD alive with disease, MSTS score Musculoskeletal Tumor Society score
Age (years)
Patient number
Table 1 Patients characteristics and outcomes
25
26
19
24
26
25
17
14
27
16
21
26
20
6
21
MSTS score (%)
7
8
8
5
11
9
10
5
14
9
8
11
9
7
10
Preoperative
14
15
13
14
14
14
13
6
15
10
13
14
12
4
12
Postoperative
Modified Allan score
Superficial wound problem
Superficial wound problem
Hip dislocation
Hip dislocation
Superficial wound problem
Superficial wound problem
Superficial wound problem
Complications
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Beijing, China), which mainly consists of iliac fixation components with variable length bush and an acetabular component. Additional pubic connection plate is available for the surgeon’s desire. In the iliac fixation component, a flat table on the horizontal plane to hold the cutting surface of the ilium and a wing plate connected with the table on the vertical plane to fit with the outer surface of ilium have been designed. The bush of the iliac fixation component can be engaged on the morse taper of the socket ball to substitute the acetabulum. A senior surgeon performed all the operations. For reducing blood loss during surgery, a balloon dilation catheter (BDC) was used to occlude the abdominal aorta in 11 patients. The surgical procedures were described thoroughly in our previous report [15]. Briefly, the patient was placed in a lateral position, and a combination of an ilioinguinal, posterior iliac, and Smith-Petersen approach was adopted. For curative purpose, intralesional curettage was not a preferential option for our patients with solitary metastasis. After refined exposure, the tumor was removed entirely with a thin layer of normal tissue as far as possible. However, compared with the resection of primary pelvic sarcomas, more muscles were retained in patients with metastatic disease for reducing postoperative complications and promoting functional recovery. To implant the modular hemipelvic prosthesis accommodating defects of various sizes, the iliac wing prosthesis with different lengths of bush was determined by trying a modular series of the iliac components. The prosthesis was assembled, fixed to the remaining ilium by screws in different directions, and augmented with cement (shown in Fig. 3). In five patients without sufficient remaining ilium, the femoral head was cut, trimmed, and used as autograft to facilitate the fixation of pelvic prosthesis. A standard cemented total hip arthroplasty was then carried out. After the reconstruction, the muscles were reattached as far as possible and the wound was closed carefully. All resected specimens were evaluated by pathologists for surgical margin study. The mean operative time was 230 min (range 180–330 min). The overall estimated blood loss ranged from 800 to 4,200 mL with a mean of 1,833 mL. Postoperatively, most patients were allowed immediate full weight bearing, as tolerated with the help of a walker. However, non-weight bearing movement was adopted in patients with autograft until 4 to 6 weeks after the operation. All patients were followed up clinically and radiologically. The oncologic parameters studied included the survival of the patients and local recurrence. Perioperative and prosthetic-related complications were recorded. The preoperative function was evaluated and compared with postoperative assessment by the modified Allan scoring system [9], which contains a total of 15 points (Table 2).
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Fig. 3 The reconstruction with a modular hemipelvic prosthesis is revealed on postoperative plain radiograph
Table 2 Modified Allan scoring system Analgesic use 1 = Constant narcotic 2 = Intermittent narcotic 3 = Constant non-narcotic 4 = Intermittent non-narcotic 5 = None Independence 1 = Total care (in a hospital, palliative care unit, or rehabilitation) 2 = Partial assistance (generally provided by family in dressing, transfers, bathing) 3 = Independent (no assistance required in activities of daily living) Ambulation and mobility 1 = Bedridden 2 = Wheelchair 3 = Non-weightbearing, household 4 = Partial weightbearing, household 5 = Non-weightbearing, community 6 = Partial weightbearing, community 7 = No walking aides
Postoperative functional outcome was also evaluated by Musculoskeletal Tumor Society (MSTS 93) system [18] at 3 months postoperative follow-up. Paired Student’s t tests were used for statistical comparison of preoperative and postoperative pain, independence, and mobility. All analyses were made using Statistical Package for the Social Sciences, Version 16.0 (SPSS, Inc, Chicago, IL).
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Results At the final follow-up, 11 patients were alive and 4 had died of their respective diseases. The mean follow-up time for living patients was 32 months (range 19–60 months) and 11 months (range 4–19 months) for non-surviving patients. After the index procedure, seven patients were alive without evidence of disease and four patients remained alive with disease. At the last follow-up, seven patients survived for more than 2 years. There were four patients with wide surgical margin, seven with marginal margin. In the remaining four patients with intralesional margin, three patients had a large tumor volume nearly 1,000 cm3, and two patients had the whole hemipelvic resection. Three patients presented local recurrence that developed at 2, 13, and 16 months after operation, respectively. Two patients had intralesional excisions, and one patient had marginal margin. One patient received hindquarter amputation for unrelieved pain and died 4 months postoperatively for systemic progression of the disease. The other two patients whose recurrence was confirmed by imaging examination had no local symptoms and received radiotherapy. No perioperative death occurred, while complications related to tumor resection and prosthetic reconstruction developed in seven patients. Five patients with superficial wound problem were treated with debridement and were healed eventually. Hip dislocation occurred in two patients at 5 and 29 days after operation, respectively. Closed reductions were carried out and postoperative functions were not affected in both patients. No deep infection, aseptic loosening, or other mechanical failure developed in this series of patients. For all patients, the average MSTS 93 score was 20.9 out of a total of 30 points (69.7%; range 20–90%). Pain was relieved in most patients, with an average rating of 3.9 of 5 points (78%). Function and emotional acceptance received average scores of 3.2 (64%) and 3.8 (76%), respectively. The average score for support was 3.3 of 5 points (66%). Ten patients were able to walk outside their house, and the average score for walking was 3.4 of 5 points (68%). All patients except one had some degree of alteration in gait. The average value was 3.2 of 5 points (64%). When evaluated according to the modified Allan scoring system, the average total score increased from 8.7 points preoperatively to 12.2 points postoperatively (p \ 0.05). The analysis of analgesic use (5 points) showed a significant pain relief in the average score from 2.6 points before surgery to 4.5 points after surgery (p \ 0.05). There were 11 patients no longer taking analgesic medicine at the 3 months postoperative follow-up time. Independence (3 points) was improved markedly from 1.9 points preoperatively to 2.5 points postoperatively (p \ 0.05). Total care
Fig. 4 The follow up of the same patient evaluated at 35 months after operation shows good hip function
was only needed in two patients. The average score of ambulation and mobility (7 points) was also increased from 4.2 points before surgery to 5.2 points after surgery (p \ 0.05). Two patients were able to walk without aides (shown in Fig. 4), while eight patients became community ambulators with partial weight bearing.
Discussion Pelvic surgery for metastatic disease around the acetabulum is challenging. Palliative efforts to provide pain relief and generally maintain ambulation are suitable for patients with diffuse disease and limited life expectation. When the metastatic disease is limited to a solitary bony lesion, en bloc resection may be more appropriate for local tumor control and possibly prolong patient survival [5–7]. The options for reconstruction after the excision of periacetabular tumor are technically difficult and limited. Allograft, recycled with tumor-bearing bone, and arthrodesis, which needs long duration of rehabilitation, should not be considered for patients with metastatic disease. Therefore, pelvic prosthesis is a reasonable choice for periacetabular reconstruction. The purpose of this study is to present our experience in providing resection and reconstruction with modular hemipelvic prosthesis in patients who had a solitary periacetabular metastasis and evaluate the oncologic results, complications, and functional outcomes.
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Our study has some limitations. First, it is limited by the small total number of patients included, although it still involved a large series of patients with solitary periacetabular metastasis. Second, the short-term follow-up for living patients makes the evaluation of long-term survival rate and complications impossible. Nevertheless, summarizing the short-term results is valuable for patients with metastatic disease. Finally, our study is limited by its retrospective design and lack of controls for comparison purposes between different reconstruction methods. Although better local tumor control could be achieved by en bloc resection, the degree of survival for patients with a solitary metastasis to bony pelvis is still unclear. The results of some studies [19, 20] showed that there was no survival advantage for patients who had a wide resection of the metastatic lesion compared with patients who had intralesional resection or internal fixation alone. However, in other studies, solitary skeletal metastases were generally associated with the best prognosis in patients with primary tumors of breast, kidney, and prostate cancer [21–23]. Even for lung cancer, the 1-year survival rate of patients with solitary bone metastasis could be more than 50% [24], and long-term survival could be achieved in a few patients [25]. Therefore, wide resection for curative purpose, local control, and maintaining implant stability are recommended in these patients [2, 20–22]. In a report [8] of solitary bone metastases of the pelvis in 14 patients (acetabulum in 6, ilium in 4, ischium in 3, pubis in 1) who received en bloc resection, 13 had negative surgical margins for tumor. Favorable results were obtained without the development of local recurrence, and six survivors had long-term survival with median of 74.5 months. In our series, the result was not very optimistic. Although en bloc resection was carried out in all 15 patients, wide or marginal margin was only achieved in 11 patients, while 3 patients presented local recurrence, and 4 had died of their respective disease during our short-term follow-up. This may be attributed to the fact that most of our patients who had intralesional margin, had a large tumor volume and a combined pelvic resection type involving the actetabulum, which induced inadequate surgical margins. The surgeon’s desire of retaining more muscles and bony structures in patients with metastatic disease for reducing postoperative complications and promoting functional recovery should also be considered. However, when compared with reports [10, 11, 26] of Harrington procedures carried out in patients with multiple metastases, in which median survival time was not more than 12 months, the oncological results of our series is acceptable with nearly half of the patients surviving for more than 24 months. The resection and reconstruction of periacetabular metastasis may be associated with a high complication rate. Common complications include perioperative death,
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dislocation, wound healing problem, deep infection, and fixation failures due to progression of disease. In a study [27] of 37 patients who underwent modified Harrington reconstruction with periacetabular screws, cement, and total hip arthroplasty, 12 patients had a total of 15 complications related to surgery, while 3 patients had complications attributable to their disease. In another report [26] of 29 patients reconstructed with protrusio cage for metastatic disease involving acetabulum, complications developed in 9 patients including dislocation in 5, deep infection in 3, and lost fixation due to disease progression in 1 patient. In studies of reconstruction with hemipelvic prosthesis, even more complications were encountered. In a series [7] of 40 patients including 11 with bony pelvic metastasis, the complication rate was 75% after reconstructed with hemipelvic endoprosthesis. The authors recommended that the indication for hemipelvic prosthesis in patients with a metastatic disease must be considered seriously. However, the complication rate of our series is acceptable and comparable to the reports of Harrington procedures. In our study, all patients with superficial wound infection and dislocation recovered uneventfully, and no other serious complications occurred. This may be attributed to patients included in this study being at the early stage of their metastatic disease, had better system condition, and did not receive radiotherapy preoperatively. Meanwhile, the attempt to reduce blood loss with BDC and maintain adequate soft tissue coverage may also contribute to the lower complication rate. Saddle prosthesis, custom-made prosthesis, and modular prosthesis have all been adopted in reconstruction for severe periacetabular metastatic disease [5, 7, 13–15]. In a series [13] of 20 patients with periacetabular metastases who received saddle prosthesis replacement, the average MSTS score was 16.6 out of the total 30 points (55%), ambulation was achieved in 16 patients. In another report [14] of reconstruction of Type II pelvic resection with periacetabular endoprosthesis, the mean MSTS scores of the ten surviving patients, including five patients of metastatic disease, was 20.1 points (11–27). The functional outcome of our reconstruction was satisfied. When evaluated with the MSTS score, which is usually adopted to appraise postoperative function in limb salvage surgery, an average score of 20.9 of 30 points (69.7%) was achieved. Most patients had a scale of good or excellent function and could ambulate without pain. Only one patient who had local recurrence and amputation had poor function and had been bed bound until death. When evaluated according to the modified Allan scoring system in which pain, independence, and mobility can be compared before and after operation, both the average total score and scores on each item increased significantly. These evaluations revealed that our reconstructions preserve good hip function and provides pain relief.
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Our experience indicates that en bloc tumor resection and reconstruction with modular hemipelvic prosthesis in patients who had a solitary periacetabular metastasis can provide long-term survive and tumor local control, low complication rate, and good functional recovery. Conflict of interest No benefits have been received from a commercial party related directly or indirectly to the subject of this article. This study complies with all current relevant laws in China, where this report was produced.
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