Internal hemipelvectomy and endoprosthetic pelvic replacement: long-term follow-up results

Abstract

We report on our experiences with internal hemipelvectomy followed by an implantation of a endoprosthetic pelvic replacement (EPR) performed in 15 patients over a period of 15 years. Our primary aim was to determine the implications for this procedure because of its high rate of complications. Due to the malignant character of the disease and the biomechanical stress on the anatomical region, the demands on the surgeon are high. The most important factor is a sufficiently wide resection of the primary tumour because most are chondrosarcomata which do not respond to other therapies. In addition, the malignant character of the tumour has the greatest influence on the long-term results. Internal hemipelvectomy and endoprosthetic pelvic replacement are accompanied by a high rate of operative and postoperative complications Nevertheless, nearly full anatomical and functional reconstruction can be obtained provided a medium level of function is accepted. Follow-up results of the remaining six still living patients were evaluated by means of three different scoring systems. All patients had only a medium score but emphasised subjective acceptance of the endoprosthetic pelvic replacement even when removal was necessary later on. Because of the lower functional outcome of alternative operative procedures such as pseudarthroses and arthrodeses and problems with the replantation of autoclaved autografts or implantation of an allograft, internal hemipelvectomy combined with endoprosthetic pelvic replacement is the treatment of choice for these specific acetabular lesions, provided a complete resection is feasible. Otherwise, an external hemipelvectomy is necessary because even alternative limb-salvaging procedures must incorporate the same complete resection of the tumour. In cases of metastatic lesions, internal hemipelvectomy and endoprosthetic pelvic replacement are indicated relatively because of the systemic character of the disease. The procedure should be considered only when resection of a solitary metastasis enables a cure and/or prolongation of life with an improved quality of life.

The use of CT derived solid modelling of the pelvis in planning cancer resections

“…We believe that the results described here are very promising despite the generally high complication rate of pelvic tumor resections (1,3,6,15,16). Also, our oncological data are acceptable and are in the range of those reported previously (1, 3,6,15,16) …”

Internal Hemipelvectomy for Pelvic Sarcomas Using a T-incision Surgical Approach

“…Comparable rates of local recurrence (15%-36%) [1,3,8,10,12] and death (23%-33% at 2 years and 28%-49% at 5 years) [1,3,12] are reported in other studies of internal hemipelvectomy for pelvic sarcomas, reflecting the inherently aggressive behavior of these tumors. It has been suggested recurrence and mortality in these patients are more closely related to presurgical disease state than to the type or extent of resection [6,21]. Kawai et al [21] found tumor size, histologic grade, and sacral involvement have a major effect on prognosis for bone sarcomas treated with internal or external hemipelvectomy [21].…”

The modified Harrington procedure for metastatic peri-acetabular bone destruction

“…Although we performed surgery in patients with many co-morbidities (four patients classified as ASA 4) with extended, generalised metastatic disease we had no intra-or postoperative deaths and observed no major complications such as excessive haemorrhage, deep infections, lesions of the femoral nerve, loss of fixation, or dislocations as described in other series after performing various methods for pelvic reconstruction [9,14,15,[17][18][19]. Tillman et al have reported similar results in their series of 19 patients treated with a three-pin modified Harrington technique with respect to occurrence of major intra-and postoperative complications as well as the functional outcome [6].…”

“…A recent study by Jansen et al reported a high risk of complications and poor long-term function in patients following acetabular reconstruction with saddle prostheses after peri-acetabular tumour surgery [15]. Another technique of endoprosthetic restoration, especially in relation to reconstruction of extended pelvic defects in cases of primary malignant tumours or solitary metastatic bony lesions of the pelvis, is the internal hemipelvectomy and reconstruction with an endoprosthetic pelvic replacement [9,[16][17][18][19]. Although this technique, first described in 1978, has been improved due to the possibility of exact planning of resection and construction of the implants using threedimensional imaging, the functional outcome has been described as limited to poor.…”

“…Although this technique, first described in 1978, has been improved due to the possibility of exact planning of resection and construction of the implants using threedimensional imaging, the functional outcome has been described as limited to poor. Furthermore, this technique seems to be associated with a high incidence of postoperative complications, such as deep infection and dislocation [9,[17][18][19].…”