[Pelvic reconstructions after bone tumor resection]. / Reconstructions du bassin après résection tumorale chez l'adulte.

The three more frequent primitive malignant bone tumour which concerned the iliac bone are chondrosarcoma, following Ewing sarcoma and osteosarcoma. Wide resection remains the most important part of the treatment associated with chemotherapy for osteosarcoma and the Ewing sarcoma. Iliac wing resections and obdurate ring don't required reconstruction. However, acetabular resections and iliac wing resection with disruption of the pelvic ring required reconstruction to provide acceptable functional result. Acetabular reconstruction remains high technical demanding challenge. After isolated acetabular resection or associated to obdurate ring, our usual method of reconstruction is homolateral proximal femoral autograft and total hip prosthesis but it is possible to also used : saddle prosthesis, Mac Minn prosthesis with auto or allograft, modular prosthesis or custom made prosthesis, massive allograft with or without prosthesis and femoro-ilac arthrodesis. After resection of the iliac wing plus acetabulum, reconstruction can be performed by femoro-obturatrice and femora-sacral arthrodesis, homolateral proximal femoral autograft and prosthesis, femoral medialisation, massive allograft and massive allograft. Carcinological results are lesser than resection for distal limb tumor, local recurrence rate range 17 to 45%. Functional results after Iliac wing and obdurate ring are good. However, acetabular reconstruction provide uncertain functional results. The lesser results arrive after hemipelvic or acetabular and iliac wing resection-reconstruction, especially when gluteus muscles were also resected. The most favourable results arrive after isolated acetabular or acetabular plus obturateur ring resection-reconstruction.

Ipsilateral femoral autograft reconstruction after resection of a pelvic tumor.

BACKGROUND: Reconstruction of bone after the resection of a pelvic tumor is challenging. The purpose of the present study was to evaluate the use of the ipsilateral femur as the graft material for reconstruction. METHODS: We performed a retrospective review of thirteen patients with a malignant pelvic lesion who underwent resection followed by reconstruction with an ipsilateral femoral autograft and insertion of a total hip replacement. The study group included nine men and four women with a median age of fifty-one years at the time of the reconstruction. The diagnosis was chondrosarcoma in eight patients, metastasis in three, and myeloma and radiation-induced malignant disease in one each. The surviving patients were assessed functionally and radiographically; the cumulative probability of revision was estimated while taking into account competing risks. RESULTS: The median duration of follow-up was forty-nine months. At the time of the latest follow-up, seven patients were alive and disease-free and six had died from metastatic disease. Four patients had had revision of the reconstruction, two for the treatment of mechanical complications and two for the treatment of infection. Three other patients had mechanical complications but had not had a revision. The cumulative probability of revision of the reconstruction for mechanical failure was 8% (95% confidence interval, 0% to 23%), 8% (95% confidence interval, 0% to 23%), and 16% (95% confidence interval, 0% to 39%) at one, two, and four years, respectively. CONCLUSIONS: Although it has attendant complications consistent with pelvic tumor surgery, an ipsilateral femoral autograft reconstruction may be an option for reconstruction of pelvic discontinuity in a subgroup of patients following tumor resection. This innovative procedure requires longer-term follow-up studies.

Function, disability, and health-related quality of life after allograft-prosthesis composite reconstructions of the proximal femur.

BACKGROUND: Factors affecting function, disability and health-related quality of life after allograft-prosthesis composite reconstructions have been poorly studied. METHODS: Retrospective study of eighteen patients who underwent reconstruction with proximal femoral allograft-prosthesis composites and answered questionnaires to assess hip function (Postel and Merle d'Aubigné, self-reported Harris Hip Score), disability (Toronto Extremity Salvage Score), and health-related quality of life (SF-36). RESULTS: The median Toronto Extremity Salvage Score was 76 (IQR: 48-85), the median self-reported Harris Hip Score was 90 (IQR: 48-95) and the median Postel and Merle d'Aubigné score was 17 (IQR: 12-17). Older age, female gender, and presentation with a pathologic fracture were associated with increased disability and poorest function. The median Physical Component Summary score was 44 (IQR: 39-45) and Mental Component Summary scores were 49 (IQR: 46-56). Male gender and recurrence of disease were associated with poorer health-related quality of life. There was a high degree of correlation between function, disability scores and Physical Component Summary score. CONCLUSIONS: Patients' characteristics at presentation such as age, gender, and occurrence of a pathologic fracture play an important role in determining disability, function, and health-related quality of life after allograft-prosthesis composite reconstruction of the proximal femur.

Allograft-prosthesis composites after bone tumor resection at the proximal tibia.

The survival of irradiated allograft-prosthesis composites at the proximal tibia is mostly unknown. However, allograft-prosthesis composites have proved beneficial at other reconstruction sites. We presumed allograft-prosthesis composites at the proximal tibia would improve survival and facilitate reattachment of the extensor mechanism compared with that of conventional (megaprostheses) reconstructions. We retrospectively reviewed 26 patients who underwent resection of proximal tibia tumors followed by reconstruction with allo-graft-prosthesis composites. Patients received Guepar massive custom-made fully constrained prostheses. Allografts were sterilized with gamma radiation, and the stems were cemented into the allograft and host bone. The minimum followup was 6 months (median, 128 months; range, 6-195 months). Fourteen patients had one or more components removed. The median allograft-prosthesis composite survival was 102 months (95% confidence interval, 64.2-infinity). Of the 26 allografts, seven fractured, six showed signs of partial resorption, and six had infections develop. Seven allografts showed signs of fusion with the host bone. Six extensor mechanism reconstructions failed. Allograft-prosthesis composites sterilized by gamma radiation yielded poor results for proximal tibial reconstruction as complications and failures were common. We do not recommend irradiated allograft-prosthesis composites for proximal tibia reconstruction.

Survival of total knee replacement with a megaprosthesis after bone tumor resection.

BACKGROUND: The use of a megaprosthesis has become the method of choice for reconstruction after bone tumor resection at the knee. However, the long-term survival of megaprostheses is poor. In this study, we sought to identify factors that were associated with implant failure and amenable to interventions designed to improve implant survival. METHODS: A retrospective review of the charts of ninety-one patients who had undergone resection of a tumor of the knee followed by reconstruction with a custom-made megaprosthesis was performed. The distal part of the femur was resected in fifty-six patients and the proximal part of the tibia, in thirty-five patients. The reconstruction was performed with an allograft-prosthesis composite in thirty-three patients and with metal or plastic sleeves in fifty-eight patients. Reconstruction of the extensor mechanism was necessary in all thirty-five patients with a tibial tumor. RESULTS: The median duration of follow-up was sixty-two months. The extensor mechanism was significantly less likely to rupture when partial continuity had been preserved at the time of the resection. Intra-axial laxity (an arc of motion of >5 degrees in the frontal plane) was significantly more common when the prosthesis had an antirotation pin than when it did not have an antirotation pin (p = 0.0023). There was mechanical failure of ten allograft-prosthesis composites and ten sleeve reconstructions. Thirty-six patients had removal of at least one component of the prosthesis. When revision due to local tumor recurrence was excluded, the median duration of prosthetic survival was 130 months following the distal femoral resections and 117 months following the proximal tibial resections. The median duration of survival was 117 months for the allograft-prosthesis composites and 138 months for the sleeve reconstructions. Body weight and activity level were independent predictors of early revision. CONCLUSIONS: The long-term survival of the knee megaprostheses in this study was poor. Mechanical failure was multifactorial and the leading cause of revision. Use of allograft-prosthesis composites and use of bushings or an antirotation pin appeared to have no mechanical benefits. We recommend that weight control programs and advice about adapting their activity level be offered to patients preoperatively.

Assessment of vascular invasion by musculoskeletal tumors of the limbs: use of contrast-enhanced MR angiography.

PURPOSE: To prospectively evaluate the accuracy of contrast material-enhanced magnetic resonance (MR) angiography in the evaluation of vascular invasion by bone and soft-tissue tumors, with surgery serving as the reference standard. MATERIALS AND METHODS: This study was approved by the regional ethics committee, and all patients gave informed consent. Preoperative MR angiograms and MR images of 31 sites in 30 patients with bone or soft-tissue sarcomas (n = 21) or other tumors (n = 9) were assessed for features of vascular invasion. All images were prospectively evaluated by two musculoskeletal radiologists working in consensus. MR images were evaluated for the presence of a fat plane between the vessels and the tumor and partial or total encasement of vessels. MR angiograms were evaluated for the presence of vascular displacement, stenosis, or occlusion. MR imaging and MR angiographic features of vascular invasion were graded. Imaging findings were correlated with surgical findings and classified as negative if there was no vascular invasion and as positive if there was vascular invasion. RESULTS: Among the 31 cases, 20 were classified as negative and 11 were classified as positive at surgery. All but three cases with a gap between the tumor and the vessels on MR images were classified as free and without adhesions at surgery. All cases with arterial stenoses at MR angiography had tumoral adhesion or tumoral encasement at surgery. MR imaging had a sensitivity of 64%, a specificity of 95%, a positive predictive value of 88% a negative predictive value of 83%, and an accuracy of 84% in the detection of vascular invasion on the basis of findings of partial or total encasement. MR angiography had a sensitivity of 82%, a specificity of 85%, a positive predictive value of 75%, a negative predictive value of 90%, and an accuracy of 84% in the detection of vascular invasion on the basis of the findings of a stenosis. CONCLUSION: On contrast-enhanced MR angiograms, findings of stenosis were sensitive and specific in the detection of arterial invasion. MR imaging evidence of partial or total encasement is highly specific in the detection of vascular invasion, while MR imaging evidence of a gap between the tumor and the vessels excludes an arterial invasion.