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 Introduction Resection of large pelvic bone tumours often results in –segmental pelvic defect –pelvic discontinuity –loss of acetabulum

CTOS, Montreal, November 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 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 Two Groups Hemipelvic graft Peri-acetabular graft

CTOS, Montreal, November 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 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 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 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 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 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 Results minimum follow up 15 months –group 1: months –group 2: months average age –group 1: 41 years (16-64) –group 2: 42 years (31-50)

CTOS, Montreal, November Histology

CTOS, Montreal, November 2004.

average surgical times group 1594 mins ( ) group 2596 mins ( ) returns to the OR –group 112 patients (63%) average 3.2 times (range 1 to 6) –group 21 patient (20%) 2 times

Group 1 hemipelvic allograft functional outcomes

CTOS, Montreal, November –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 –MSTS9345% –average time to score52 months ( )

CTOS, Montreal, November –9 patients had deep infection (47%) –1 patient 2° to unrelated peritoneal sepsis 3 patients maintained a functional implant with long term antibiotic suppression –TESS30 ( ) –MSTS8715/35(12-17/35) –MSTS9341%(33-50) –average time to scores30 months (6-60) 1 patient –allograft removal 4 patients –hindquarter amputation 1 patient –allograft fragmentation in situ

Group 2 periacetabular reconstruction functional outcomes

CTOS, Montreal, November –3 patients no complications –2 patients complications –1case - 1 dislocation –1 case - 3 dislocations + ? ant. acetabular wall allograft #

CTOS, Montreal, November –functional scores TESS78 MSTS8717/35 MSTS9364% –time to scores average55 months range months

The good

CTOS, Montreal, November 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 yrs, male 3 years post extra articular resection prox femoral chondrosarcoma doing well single cane

The not so good

CTOS, Montreal, November yrs, male 9 yrs post type I + II + III resection for chondrosarcoma chronic infection managed with suppressive antibiotics large inguinal hernia uses 2 crutches

The bad

CTOS, Montreal, November yrs, male 5 yrs post type Is + II + III for chondrosarcoma wound necrosis, infection, antibiotic suppression, allograft fracture 2 crutches / wheelchair

CTOS, Montreal, November 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

CTOS, Montreal, November In comparison smaller structural allograft and THA composite reconstructions for type II acetabular resections –more predictable and have a better outcome –resulting in a good level of function –lower complication rate