Reconstruction after periacetabular tumor resection with Lumic® endoprosthesis: What are the midterm results?

INTRODUCTION: This study aimed to analyze the midterm outcomes of LUMiC® endoprosthetic reconstruction following periacetabular resection of primary bone sarcomas and carcinoma metastases. PATIENTS AND METHODS: We retrospectively reviewed the charts of 21 patients (11 male [52.3%], 10 female [47.6%]; mean age 47 ± 16 years) for whom a LUMiC® endoprosthesis (Implantcast) was used to reconstruct a periacetabular defect after internal hemipelvectomy. The tumor was pathologically diagnosed as Ewing's sarcoma in six (28.5%), chondrosarcoma in 10 (47.6%), and bone metastasis from carcinoma in five (23.8%) patients. RESULTS: The median follow-up of patients was 57.8 months (95% confidence interval: 51.9-63.7). The implant survival rate at 1, 2, and 5 years were 95.2%, 85.7%, and 80.9%, respectively. The overall complication rate was 33.3% (n = 7). Four (19%) complications resulted in reconstruction failure. Total reoperation rate was 28.5% (n = 6). The complications were soft tissue failure/dislocation in two patients, aseptic loosening in one, infection in two, and local recurrence in two. At the time of study, seven patients were alive with no evidence of disease, seven were alive with disease, and seven died of disease. The 5-year overall survival rate and local recurrence-free survival rates were 67% and 76%, respectively. The median Musculoskeletal Tumor Society score at final follow-up was 70% (range: 50%-86.6%). CONCLUSION: We conclude that LUMiC® endoprosthesis provides good functional outcomes and a durable reconstruct. Even though this reconstruction method presents some complications, it provides a stable pelvis in the management of periacetabular malignant tumors.

Extremity free fillet flap for reconstruction of massive oncologic resection-Surgical technique and outcomes.

BACKGROUND AND OBJECTIVES: The purpose of this study is to present our experience using free fillet flaps to reconstruct massive oncologic defects of the upper and lower extremity. METHODS: A retrospective chart review was performed to include patients who underwent oncologic resection followed by reconstruction using free fillet flaps from July 2001 to October 2018. Patient demographics, clinical and surgical characteristics, and postoperative complications were reviewed. RESULTS: In total, 12 patients were identified and included in this study. Mean age was 48.9 years old. Five patients had extended forequarter amputations and seven patients had external hemipelvectomies, all for locally advanced tumors. Mean tumor size was 15 ± SD 6.4 cm, and negative tumor margins were achieved in all the patients. Mean flap size was 1028 ± SD 869 cm2 . The mean follow-up was 13 months. There were no partial or total flap losses in the postoperative period. Two patients had flap-related postoperative complications, including flap bleeding and wound dehiscence. Median survival was 18 months. CONCLUSION: The free fillet flap is a safe, reliable, and valuable approach for reconstructing oncological defects. It offers the advantage of avoiding donor site morbidity, while providing extensive soft-tissue coverage as a one-step solution for massive oncologic defects.

Oncologic Outcome and Quality of Life After Hindquarter Amputation for Sarcoma: Is it Worth it?

BACKGROUND AND OBJECTIVE: Hindquarter amputations for bone or soft tissue sarcoma cause a high degree of disability. The goal of this study was to analyze oncologic outcome and quality of life after resection in order to better select patients who are more likely to benefit from this operation. METHODS: Patients treated with a hindquarter amputation between 1989 and 2015 for a bone or soft tissue sarcoma were selected from our database. Clinical and histopathological features were analyzed for their prognostic value using Kaplan-Meier and Cox proportional hazard analysis. In addition, performance status, ambulatory status, and pain were assessed from the hospital charts for patients surviving longer than 1 year after surgery. RESULTS: Overall, 78 patients underwent a hindquarter amputation for sarcoma. The median hospital stay was 24 days and 49% of patients had wound complications. In-hospital mortality was 6%. Overall survival for patients with metastases at presentation was significantly worse than patients with localized disease only (p = 0.001, 5-year survival 41 vs. 0%). For patients treated for localized disease, the combination of age >65 years and tumor size ≥15 cm was significantly correlated with worse metastasis-free survival (p = 0.003) and overall survival (p = 0.01). In particular, patients younger than 65 years of age who survived more than 1 year had an acceptable performance status, with reasonable pain levels and mobility. CONCLUSION: Younger patients are more likely to benefit from hindquarter ampuations in terms of survival and functionality; however, for older patients with large tumors, a hindquarter amputation might not be beneficial.

Hindquarter amputation: is it still needed and what are the outcomes?

A total of 157 hindquarter amputations were carried out in our institution during the last 30 years. We have investigated the reasons why this procedure is still required and the outcome. This operation was used as treatment for 13% of all pelvic bone sarcomas. It was curative in 140 and palliative in 17, usually to relieve pain. There were 90 primary procedures (57%) with the remaining 67 following the failure of previous operations to control the disease locally. The indication for amputation in primary disease was for large tumours for which limb-salvage surgery was no longer feasible. The peri-operative mortality was 1.3% (n = 2) and major complications of wound healing or infection arose in 71 (45%) patients. The survival at five years after hindquarter amputation with the intent to cure was 45%, and at ten years 38%. Local recurrence occurred in 23 patients (15%). Phantom pain was a significant problem, and only 20% used their prosthesis regularly. Functional scores were a mean of 57%. With careful patient selection the oncological results and functional outcomes of hindquarter amputation justify its continued use.

En bloc resection of extra-peritoneal soft tissue neoplasms incorporating a type III internal hemipelvectomy: a novel approach.

BACKGROUND: A type III hemipelvectomy has been utilized for the resection of tumors arising from the superior or inferior pubic rami. METHODS: In eight patients, we incorporated a type III internal hemipelvectomy to achieve an en bloc R0 resection for tumors extending through the obturator foramen or into the ischiorectal fossa. The pelvic ring was reconstructed utilizing marlex mesh. This allowed for pelvic stability and abdominal wall reconstruction with obliteration of the obturator space to prevent herniations. RESULTS: All eight patients had an R0 resection with an overall survival of 88% and with average follow up of 9.5 years. Functional evaluation utilizing the Enneking classification system, which evaluates motion, pain, stability and strength of the affected extremity, revealed a 62% excellent result and a 37% good result. No significant complications were associated with the operative procedure. Marlex mesh reconstruction provided pelvic stability and eliminated all hernial defects. CONCLUSION: The superior and inferior pubic rami provide a barrier to a resection for tumors that arise in the extra-peritoneal pelvis extending through the obturator foramen or ischiorectal fossa. Incorporating a type III internal hemipelvectomy with a simple marlex mesh reconstruction allows for complete tumor resection without functional compromise, acute infectious issues, obturator or abdominal hernia defects.

Hemipelvectomy: a changing perspective for a rare procedure.

OBJECTIVE: To compare the prognosis of patients undergoing a hemipelvectomy (HP) in the treatment of pelvic sarcomas and carcinomas and to review the morbidity and mortality associated with HP. DESIGN: Retrospective chart review. SETTING: The Foothills Hospital, University of Calgary, Calgary, Alberta. PATIENTS: Thirteen patients with clinically and radiographically isolated malignancies involving the bony pelvis and adjacent structures. INTERVENTIONS: Patients were treated with either an external HP (9 patients) or internal HP (4) in 1983-2001. OUTCOME MEASURES: Survival and recurrence rates for patients in 2 histopathologic groups (sarcoma v. carcinoma); morbidity and mortality associated with HP. RESULTS: Hemipelvectomy was performed for 7 sarcomas (4 primary bone and 3 soft tissue) and 6 carcinomas (5 genital tract and 1 unknown primary). Seven of the 9 external HPs involved composite resection of other pelvic structures, including other pelvic viscera (3 patients), sacrum (3) and portions of lumbar vertebrae and nerves (1). There were no additional resections among the 4 internal HPs, but 3 patients had allograft reconstruction. Length of stay averaged 30 days (range 14-70 d). At least 1 complication occurred in 10 of 13 cases. The most common complication was flap necrosis occurring in 5 patients (38%). There was 1 perioperative death (8%). The survival of patients treated for sarcomas was better than for carcinomas, which were primarily of the genital tract. Only 1 of the patients with a pelvic sarcoma died of disease (86% disease-specific survival), with a median follow-up of 12 months (range 9-108 mo). Of the 7 sarcoma patients 5 were disease-free at last follow-up. One of 6 pelvic carcinoma patients died perioperatively, with another dying of unknown causes 4 months after surgery. Of the 4 remaining patients 3 died of disease, resulting in a median survival of 9 months (range 4-20 mo). Four of 6 patients with pelvic carcinomas developed recurrent disease, none local. CONCLUSIONS: HP has considerable morbidity but is a viable and potentially curative treatment for patients with pelvic sarcomas. With pelvic carcinomas HP was not curative, but did provide short-term local disease control. Future improvements in imaging techniques and quality-of-life studies may help with patient selection. The role of HP in recurrent carcinoma remains to be determined.

[Ablative procedures in surgical treatment of malignant bone tumors]. / Ablative Verfahren bei der operativen Behandlung maligner Knochentumoren.

Limb-sparing surgery is the treatment of choice for primary malignant bone tumors. However, ablative procedures cannot always be avoided. The indication to sacrifice the limb depends on localization, size, and biology of the tumor and does not represent failure of treatment primarily. Amputation of the limb is necessary if there is no other operative procedure to achieve negative surgical margins even if all adjunctive therapeutic options have been considered. Primary ablative resections may be indicated with both curative and palliative intent. Secondary ablative procedures mainly result from local recurrence. Late complications of endoprosthetic or allograft reconstruction also may necessitate ablative surgery. In this paper, general guidelines for ablative surgeries are presented. Following amputation, early prosthetic repair of the extremity is the goal. In those patients with consolidated stump development definitive prosthesis should be adapted. Results of hemipelvectomy and forequarter amputation from our institution are reported. However, this group of patients together with those undergoing shoulder exarticulation and forequarter amputation represent situations with no prosthetic repair possible. The loss of an extremity induces disability and restriction of ego, physical integrity, and quality of life. However, it should be borne in mind that amputation could represent the only chance of cure sometimes. Sharing the decision-making between patient and physician for this procedure is an important step to develop confidence in the therapeutic process. In this setting, direct contact between patients being confronted with the option of an amputation and those patients having already undergone rehabilitative procedures might be very useful.

Hip disarticulation. An 11-year experience.

Thirty-eight hip disarticulations performed in 34 patients were retrospectively reviewed. The indications were ischemia secondary to atherosclerosis in 17 cases, femoral osteomyelitis in 10, and trauma in 11. Patient ages ranged from 20 to 95 years. The mortality was 60% in patients with ischemia with preoperative infection, 20% in patients with ischemia without preoperative infection, 22% in patients with femoral osteomyelitis, 100% in patients with trauma with preoperative infection, and 33% in patients with trauma without preoperative infection. The overall mortality was 44%. Postoperative wound infections were frequent (63%) and had poor correlation with the presence of a preoperative wound infection. No patient was able to use a prosthesis after hip disarticulation, but most were independent in wheelchairs.

[Results of interilioabdominal amputations]. / O rezul'tatakh mezhpodvzdoshno-briushnykh amputatsii.

Twenty four interilioabdominal amputations for malignant tumors are described. Malignant tumors of the proximal portion of the femur or pelvis were taken as indications for surgery. The Salishchev incision was used. The main steps of the operation are given. Two patients died immediately after the operation. The fate of the other 22 patients was followed: 17 patients died within 3 years after the operation, 3 patients survived for more than 5 years. The worst results were obtained in osteogenic sarcomas and Ewing's sarcomas.