Transcript Document 7461120

Outcome Following Pelvic Sarcoma
Resection Reconstructed With
Saddle Prosthesis
F.Aljassir MD, FRSCC.
G.Beadel MB ChB.
R.Turcotte MD, FRSCC.
A.Griffin BSc.
R.S.Bell MD, FRSCC .
J.S.Wunder MD, FRSCC.
M.H.Isler MD, FRSCC.
Introduction.

Pelvic sarcomas remain a difficult problem.

Classically, hemipelvectomy was the primary
means of surgical intervention.

With the advent of aggressive chemotherapy,
better imaging studies and more advanced
surgical techniques, limb-sparing resections have
been increasingly used .

Techniques of surgical reconstruction include:
1- Ischiofemoral arthrodesis or pseudoarthrosis.
2-Iliofemoral arthrodesis or pseudoarthrosis.
3-Massive allograft or autoclaved autograft with
hip arthroplasty.
4-Flail extremity.
5-Custom made metallic prostheses.
6-Saddle prosthesis.
3-Saddle
2-body
1-stem
The saddle is free to rotate on the body component. The entire
prosthesis can abduct, adduct, flex, and extend through the
saddle and iliac “articulation”.
In the literatures there are few clinical
studies of the saddle prosthesis
 1-Nieder
et al (seven:ISOLS, 313, 1993].
- 72 patients (failed of hip arthroplasty).
-1 excellent , 14 good , 36 fair , and 21 poor.
-Infection in 15 patients lead to poor results.
 2-Aboulafia
et al :
( Clin
Orthop 314:203-213,1995).
-17 patients,
-mean follow up of (33 mon).
-Favorable results:
(excellent in 10, good in 2, fair in 1, and poor in 4.

3- Windhager et al (Clinical ortho (1996) 331:265-276.)
-22 patients (6 had saddle prosthesis)
-Custom-made pelvic had better functional results.
-Eccentric new hip centre { limited motion}.

4-Renard et al (Arch Orthop Trauma Surg(2000) 120:188-194)
-15 patients.
-Satisfactory results in short term follow up.

5-Cottias et al (Journal of surgical oncology 2001;78:90-100.)
-17 patients, with mean follow up of 42 months
-early pain free weight bearing,
-minimal limb shortening
-functional results remained fair in most patients.
Objectives:
 To
evaluate the outcome after
resection of pelvic sarcoma and
reconstruction with a saddle
prosthesis.
Material & Methods.

Retrospective study, 27 patients (1991 to
2001). (Maisonneuve- Rosemont Hospital
(Montreal) and Mt Sinai Hospital (Toronto).

Functional outcome was assessed with MSTS
1987 & 1993 and the Toronto Extremity
Salvage Score (TESS).

Oncological outcome parameters and
complications were recorded.
Patients Demographic

Gender: 18 male (67%) / 9 female (33%).
 Age: ( 24 to 75 years ) ,
mean (SD) (53 (16)).
 Follow up: ( 12 to 120 months),
mean (45 months).
 Operative time: ( 300 to 900 minutes ),
mean (SD) ( 600 (98 )).
 Blood transfusions: from 4 to18 units,
mean (SD) (10 (6)).
Diagnosis
20
18(66.7%)
15
frequency. 10
4(14.8%)
2(7.4%) 1(3.7%)
5
1
1
0
ChSA
Ch.SA
OSA
O.SA
MFH
MFH
EHE
H.E
mGCT
GCT
EWSA
Ew.
Metastasis at diagnosis
20 (74%)
20
15
Frequency 10
4 (15%)
5
2 (7.4%)
1 (3.7%)
0
NO- Mets
Lung- Mets
Site
Ing. L.N.
L.Spine
TYPE I (ilium)
Type of pelvic resection
19 (70.3%)
20
TYPE II (periacetabular)
15
Number of
10
cases
7 (26%)
1(3.7%)
5
TYPE III (pubis)
0
II
II & III
I, II & III
Enneking WF. The anatomic considerations in tumor surgery:
pelvis. In: Enneking WF, editor. Musculoskeletal Tumor Surgery, Vol. 2. New
York: Churchill Livingstone.1983: 483–529.
Musculoskeletal Cancer
Surgery(2001).
Martin Malawar
Margins of Resection
Intralesional
(4) 15%
Wide
(12) 44%
Marginal
(11) 41%
(Enneking WF, Spanier SS, Goodman MA. Asystem for the surgical staging of
musculoskeletal sarcoma: Clinical Orthop. 1980 Nov- Dec;(153): 106-20).
Number of Patients
Chemotherapy.
18
16
14
12
10
8
6
4
2
0
16 (59.2%)
6(22.2%)
2 (7.4%)
No
PreOp.
PostOp.
3(11.1%)
Pre.&Post Op
No radiation therapy given to any patient
Complications.
Infection in 10 (37%)
4 were superficial and 6 (22%) were deep.
Heterotropic ossification in 10 (37%).
post op.
One year post op.
Complications.

Dislocations in 6 (22.2%).

Fractures in 6 (22.2%)

Nerve Injuries in 5 (18.5%).

Others (2 dissociations, 3 DVT, and one MI).
Vertical
migration
1
3
22
4
Mean Of Vertical
Migration (MM)
Vertical Migration Of Saddle Prosthesis
14
12
10
8
6
4
8.3
10.5
9.5
11
12
3.5
2
0
0
0
10
20
30
40
Follow Up Visit (Months)
50
60
Oncological Outcome.
At mean f/u (45 months).
ONCOLOGY OUTCOME
14 (52%)
14
11 (40.6%)
12
10
number of
patients
8
6
4
2 (7.4%)
2
0
AWD
AWED
AWOD
ANED
DOD
DCD
Oncological Outcome.
At mean f/u (45 months).
Metastasis at follow up.
14 (52%)
14
12
10
number of 8
patients
6
4
2
0
5 (18.5%)
1 (3.7%)
No- Mets
Lung- Mets
Site
contralateral
ASIS
Oncological Outcome.

At mean f/u (45 months).
Local recurrence in our study:
6/27 (22.2%)
4/6 (67%) had positive resectional margins.
 Survival
rate is (60%)
Functional Outcomes.
Mean (15)
MSTS 87
*is similar to other study :
1-mean =17, ( 11to 23).
{ functional evaluation of 17 Saddle)
6
Cottias et al Journal of surgical
5
oncology 2001; 78:90-100.
2-Mean=17.6, (13 to 26).
4
(endoprosthetic pelvic
replacement)
Bruns et al (Arch Orthop Trauma
3
2
Surg(1997)116:27-31).
Std. Dev = 6.09
1
Mean = 15.3
N = 18.00
0
0.0
5.0
10.0
15.0
SCORE {range 1 to 26 }
20.0
25.0
*And lower compare to prox imal femoral replacement:
Mean =23.2 (13 to 33)
Ogilivie et al clinical orthopedic
and related research 2004;426:44-48
Functional Outcomes. 
MSTS 93
Mean (51%)
Custom made prosthetic
reconstruction: mean( 70%)
Abudu et al ( JBJS Br. 1997;79B:773-9).
5

4
Endoprosthetic pelvic
(51%).
replacement ,
Bruns et al (Arch Orthop Trauma
3
Surg(1997)116:27-31).
2
1
Std. Dev = 21.61
Mean = 50.8
N = 17.00
0
20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0
SCORE % { range 16.7 t0 90 ).

Proximal femoral
replacement:
Mean=67.7% (40-93%)
Ogilivie et al clinical orthopedic
and related research 2004;426:44-48
Functional Outcomes.
TESS

Mean (64%)
TESS of limb sparing for
lower limb sarcoma (distal
thigh):
mean (85%)
6
Davis et al, Arch Phys Med
5
Rehabbil. 1999 jun ;80960:615-8.
4

3
For proximal femoral
replacement:
Mean = 76% , (40-98)
2
Ogilivie et al clinical orthopedic
and related research 2004;426:4448
Std. Dev = 17.16
1
Mean = 64.4
N = 17.00
0
30.0
40.0
50.0
60.0
70.0
80.0
90.0

Mean = 58%, (39-95)
{ functional evaluation of 17 Saddle)
SCORE ( %) [range 26% t0 91%].
Cottias et al (Journal of surgical
oncology 2001; 78:90-100).
Functional Outcome

Work Status:
 Gait
•
L.L.D: range between 1 and
6 cm, with a mean of 3cm.
A cane in 8 patients (30%).
•
Crutches in 5 (18.5%).
•
Walker in 3 patients (11.1%).
•
Shoe lift in 5 patients.
•
A.F.O in 3 patients.
*Full time 5 patients (18.5%).
*Early retirement 5 (18.5%).
aids:
*Disabled 6 (22.2%).
*Deceased 11(40.6%).
Discussion.

In pelvic sarcoma goals are to cure the patient
and to preserve the best function and quality of
life.

Treatment of pelvic sarcoma remains difficult.

Limited data exists to compare functional
outcome.

The most common complications are infection
and heterotopic ossification.
Conclusion.

Like with other implants, the oncological and
functional outcome in limb salvage procedures
using a saddle prosthesis remain difficult to
predict, and is associated with significant risk of
morbidity and complications.

However, the functional results appear to confer
an advantage compared to the expected
disability following hemipelvectomy.