Rebuilding and Prostheses in the Event of Periacetabular Tumors

Using described criteria for the selection of patients for excision or resection of tumors involving various portions of the innominate bone, as opposed to hemipelvectomy, fifty-seven out of the more than 200 patients evaluated were judged to be candidates for a curative procedure. Of these, twenty-five were selected for hemipelvectomy and thirty-two, for non-amputative procedures. Depending on the location and extent of the lesion as determined by complete preoperative work-ups, three types of procedures were performed singly or in combination:(1) wide excision or radical resection of the iliac wing; (2) periacetabular wide excision or radical resection; or (3) wide excision or radical resection of the pubis. Reconstruction was accomplished when the hip joint was excised by fusion or the creation of a pseudarthrosis either medially in relation to the pubis or laterally in relation to the ilium or wing of the sacrum. The results after follow-ups of one to seventeen years were assessed in terms of the immediate goals of surgery, control of the disease, and function. The findings were as follows: With the preoperative assessment and operative techniques described, an oncologically adequate procedure was performed in two-thirds of the cases. In the remaining cases, the adequacy of the procedure was compromised by poorly planned biopsies, occult microextensions, and surgical errors. The recurrence rate was high after the inadequate procedure (100 per cent) and low (4 per cent) after the adequately accomplished procedures. Function was nearly normal when the hip joint was preserved. If the hip joint was removed and fusion was obtained, the results were good, but fusion was obtained in only 50 percent of the cases in which it was attempted. If the hip joint was removed and pseudarthrosis resulted, the results ranged from good to poor. Sciatic-nerve involvement necessitating resection of the nerve was not a contraindication to a non-amputative procedure.

Fourteen patients who had a malignant tumor of the pelvic bone, adjacent to the acetabulum, were managed with a wide en bloc resection that included most of the hemipelvis as well as the hip. Reconstruction was done with either a massive allograft or replacement of the resected bone after it had been autoclaved. The duration of follow-up ranged from four to eleven years, with a mean of seven years. One osteosarcoma recurred locally, and a repeat excision was done. Two patients who had had a solitary supra-acetabular metastasis preoperatively had systemic metastases much later, but no local recurrence. At the most recent follow-up examination, twelve patients had no evidence of tumor, and all had a functioning lower limb. After a minimum of two years, all grafts had healed and were structurally normal as seen roentgenographically. Later, however, three of the fourteen grafts had failed by fracture, and numerous other complications were evident. The described regimens offer superior functional results compared with other options for management, despite the complications.

Since 1971, the Orthopaedic Service at the Massachusetts General Hospital has treated 106 patients with malignant or aggressive bone tumors by wide resection and replacement with frozen cadaveric allograft. Sixty-one of these patients have been followed for over two years (mean, 4.5 years), allowing a comprehensive end-results analysis. In 45 patients, mostly with giant-cell tumors of chondrosarcomas, the resection involved the articular end of a long bone and the replacement not only included bone, but glycerolized (to prevent freezing injury) and articular cartilage. Ten of the segments were intercalary (bone alone) and six involved a combination of bone and metallic joint prosthesis. Patients were graded as excellent, good, fair, or failure, depending principally on functional capacity. End-results analysis in this group showed that five of the 61 patients had either a local recurrence (2) and/or distant metastases (3); in five additional patients the limb was amputated or the implant removed, primarily because of infection (total failure rate, 16.5%). Forty-five (73.8%) had successful transplants (graded excellent or good) and were able to live essentially normal lives. Six of the patients (10%) required a brace or cane but three of these patients were able to return to preoperative work activities. Although the operations were arduous and difficult, and despite a high infection rate (13%) and occasional pathologic fractures (10%), the results compare favorably with other techniques used to restore the skeleton following massive segmental resection. In long-term follow-up, the data suggest that if no complication ensue in the first two years, the results are generally quite good and the grafts show no evidence of progressive deterioration with time.