Outcome Following Pelvic Sarcoma Outcome Following Pelvic Sarcoma Resection Reconstructed With Resection Reconstructed With
Saddle Prosthesis 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.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.
The saddle The saddle is free to rotate on the body component. is free to rotate on the body component. The entire prosthesis can abduct, adduct, flex, and extend The entire prosthesis can abduct, adduct, flex, and extend
through the saddle and iliac “articulation”.through the saddle and iliac “articulation”.
1-stem1-stem1-stem1-stem
2-body2-body
3-Saddle3-Saddle
In the literatures there are few clinical In the literatures there are few clinical studies of the saddle prosthesisstudies 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:Objectives:
To evaluate the outcome after resection of pelvic sarcoma and reconstruction with a saddle prosthesis.
Material & Methods.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 DemographicPatients 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)).
18(66.7%)
4(14.8%)2(7.4%) 1(3.7%)
1 1
0
5
10
15
20
frequency.
Ch.SA O.SA MFH H.E GCT Ew.
Diagnosis
ChSAChSA OSAOSA EHEEHE mGCTmGCT EWSAEWSAMFHMFH
20 (74%)
4 (15%) 2 (7.4%) 1 (3.7%)
0
5
10
15
20
Frequency
NO- Mets Lung- Mets Ing. L.N. L.Spine
Site
Metastasis at diagnosis
7 (26%)
19 (70.3%)
1(3.7%)
0
5
10
15
20
Number of cases
II II & III I, II & III
Type of pelvic resection
Enneking WFEnneking WF.. The anatomic considerations in The anatomic considerations in tumor surgery: pelvis. In: Enneking WF, editor. Musculoskeletal tumor surgery: pelvis. In: Enneking WF, editor. Musculoskeletal Tumor Surgery, Vol. 2. New York: Churchill Livingstone.1983: Tumor Surgery, Vol. 2. New York: Churchill Livingstone.1983:
483–529.483–529.
TYPE I (ilium)TYPE I (ilium)TYPE I (ilium)TYPE I (ilium)
TYPE II (periacetabular)TYPE II (periacetabular)TYPE II (periacetabular)TYPE II (periacetabular)
TYPE III (pubis)TYPE III (pubis)
Musculoskeletal Cancer Surgery(2001).
Martin Malawar
Musculoskeletal Cancer Surgery(2001).
Martin Malawar
((Enneking WFEnneking WF, , Spanier SS, Goodman MA. Asystem for the Spanier SS, Goodman MA. Asystem for the surgical staging of musculoskeletal sarcoma: Clinical Orthop. 1980 Nov- surgical staging of musculoskeletal sarcoma: Clinical Orthop. 1980 Nov-
Dec;(153): 106-20).Dec;(153): 106-20).
Margins of Resection
Intralesional(4) 15%
Wide(12) 44%
Marginal(11) 41%
Chemotherapy.
16 (59.2%)
6(22.2%)
2 (7.4%)3(11.1%)
02468
1012141618
No PreOp. PostOp. Pre.&Post Op
Num
ber
of P
atie
nts
No radiation therapy given to any patientNo radiation therapy given to any patient No radiation therapy given to any patientNo radiation therapy given to any patient
Complications.Complications.Infection in 10 (37%)
4 were superficial and 6 (22%) were deep.
Heterotropic ossification in 10 (37%).
One year post op.One year post op.One year post op.One year post op.post op.post op.
Complications.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 Vertical migrationmigration
Vertical Vertical migrationmigration
11 22
4433
22
Vertical Migration Of Saddle Prosthesis
0
3.5
8.39.5
10.5 1112
02
468
10
1214
0 10 20 30 40 50 60
Follow Up Visit (Months)
Mea
n O
f Ver
tical
M
igra
tion
(MM
)
Oncological Outcome.Oncological Outcome.
2 (7.4%)
14 (52%)
11 (40.6%)
0
2
4
6
8
10
12
14
number of patients
AWED ANED DOD
ONCOLOGY OUTCOME
DCD DCD DCD DCD
At mean f/u (45 months).At mean f/u (45 months).At mean f/u (45 months).At mean f/u (45 months).
AWODAWODAWDAWD
Oncological Outcome.Oncological Outcome.At mean f/u (45 months).At mean f/u (45 months).At mean f/u (45 months).At mean f/u (45 months).
14 (52%)
5 (18.5%)
1 (3.7%)
02468
101214
number of patients
No- Mets Lung- Mets contralateralASIS
Site
Metastasis at follow up.
Oncological Outcome.Oncological Outcome.
Local recurrence in our study:
6/27 (22.2%) 4/6 (67%) had positive resectional margins.
Survival rate is (60%)
At mean f/u (45 months).At mean f/u (45 months).At mean f/u (45 months).At mean f/u (45 months).
Functional Outcomes.Functional Outcomes.
SCORE {range 1 to 26 }
25.020.015.010.05.00.0
MSTS 87
Freq
uenc
y
6
5
4
3
2
1
0
Std. Dev = 6.09
Mean = 15.3
N = 18.00
*is similar to other study :
1-mean =17, ( 11to 23).{ functional evaluation of 17 Saddle)
Cottias et al Journal of surgical oncology 2001; 78:90-100.
2-Mean=17.6, (13 to 26). (endoprosthetic pelvic replacement)Bruns et al (Arch Orthop Trauma Surg(1997)116:27-31).
*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
Mean (15)Mean (15)
Functional Outcomes.Functional Outcomes.
SCORE % { range 16.7 t0 90 ).
90.080.070.060.050.040.030.020.0
MSTS 93
Freq
uenc
y
5
4
3
2
1
0
Std. Dev = 21.61
Mean = 50.8
N = 17.00
Custom made prosthetic reconstruction: mean( 70%)
Abudu et al ( JBJS Br. 1997;79-B:773-9).
Endoprosthetic pelvic
replacement , (51%). Bruns et al (Arch Orthop Trauma
Surg(1997)116:27-31).
Proximal femoral replacement:
Mean=67.7% (40-93%)
Ogilivie et al clinical orthopedic and related research 2004;426:44-48
Mean (51%)Mean (51%)
Functional Outcomes.Functional Outcomes. TESS of limb sparing for lower limb sarcoma (distal thigh):
mean (85%) Davis et al, Arch Phys Med
Rehabbil. 1999 jun ;80960:615-8.
For proximal femoral replacement:
Mean = 76% , (40-98) Ogilivie et al clinical orthopedic
and related research 2004;426:44-48
Mean = 58%, (39-95) { functional evaluation of 17 Saddle)
Cottias et al (Journal of surgical oncology 2001; 78:90-100).
SCORE ( %) [range 26% t0 91%].
90.080.070.060.050.040.030.0
TESS
Freq
uenc
y
6
5
4
3
2
1
0
Std. Dev = 17.16
Mean = 64.4
N = 17.00
Mean (64%)Mean (64%)
Functional OutcomeFunctional Outcome
Work Status:*Full time 5 patients (18.5%).
*Early retirement 5 (18.5%).
*Disabled 6 (22.2%).
*Deceased 11(40.6%).
Gait aids: L.L.D: range between 1 and 6 L.L.D: range between 1 and 6
cm, with a mean of 3cm.cm, with a mean of 3cm.• A cane in 8 patients (30%).A cane in 8 patients (30%).
• Crutches in 5 (18.5%).Crutches in 5 (18.5%).
• Walker in 3 patients (11.1%).Walker in 3 patients (11.1%).
• Shoe lift in 5 patients.Shoe lift in 5 patients.
• A.F.O in 3 patients.A.F.O in 3 patients.
Discussion.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.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.
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