Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone

1. 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

2. Introduction • Resection of large pelvic bone tumours often results in • segmental pelvic defect • pelvic discontinuity • loss of acetabulum CTOS, Montreal, November 2004.

3. 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 2004.

4. 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 2004.

5. Two Groups Peri-acetabular graft Hemipelvic graft CTOS, Montreal, November 2004.

6. 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 2004.

7. 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 2004.

8. 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 2004.

9. 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 2004.

10. 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 2004.

11. 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 2004.

12. Results • minimum follow up 15 months • group 1: 17-167 months • group 2: 15-154 months • average age • group 1: 41 years (16-64) • group 2: 42 years (31-50) CTOS, Montreal, November 2004.

13. Histology CTOS, Montreal, November 2004.

14. CTOS, Montreal, November 2004.

15. average surgical times • group 1 594 mins (450-728) • group 2 596 mins (510-704) • returns to the OR • group 1 12 patients (63%) • average 3.2 times (range 1 to 6) • group 2 1 patient (20%) • 2 times CTOS, Montreal, November 2004.

16. Group 1 hemipelvic allograftfunctional outcomes

17. 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 • MSTS93 45% • average time to score 52 months (3 - 120) CTOS, Montreal, November 2004.

18. 9 patients had deep infection (47%) • 1 patient 2° to unrelated peritoneal sepsis • 3 patients maintained a functional implant with long term antibiotic suppression • TESS 30 (22.2-37.5) • MSTS87 15/35 (12-17/35) • MSTS93 41% (33-50) • average time to scores 30 months (6-60) • 1 patient • allograft removal • 4 patients • hindquarter amputation • 1 patient • allograft fragmentation in situ CTOS, Montreal, November 2004.

19. Group 2 periacetabular reconstruction functional outcomes

20. 3 patients • no complications • 2 patients • complications • 1case - 1 dislocation • 1 case - 3 dislocations + ? ant. acetabular wall allograft # CTOS, Montreal, November 2004.

21. functional scores • TESS 78 • MSTS87 17/35 • MSTS93 64% • time to scores • average 55 months • range 12 - 120 months CTOS, Montreal, November 2004.

22. The good

23. 47 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 2004.

24. 53 yrs, male • 3 years post extra articular resection prox femoral chondrosarcoma • doing well • single cane CTOS, Montreal, November 2004.

25. The not so good

26. 65 yrs, male • 9 yrs post type I + II + III resection for chondrosarcoma • chronic infection managed with suppressive antibiotics • large inguinal hernia • uses 2 crutches CTOS, Montreal, November 2004.

27. The bad

28. 60 yrs, male • 5 yrs post type Is + II + III for chondrosarcoma • wound necrosis, infection, antibiotic suppression, allograft fracture • 2 crutches / wheelchair CTOS, Montreal, November 2004.

29. 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 2004.

30. 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 CTOS, Montreal, November 2004.