ORTHOPAEDICS ANZJSurg.com
Internal hemipelvectomy with reconstruction for primary pelvic neoplasm: a systematic review Qing Dong Shao, Xu Yan, Jiu Yi Sun and Tian Ming Xu Department of Orthopedics, PLA Fourth Fifty-Five Hospital (455 Hospital), Shanghai, China
Key words bone graft, hemipelvectomy, pelvic neoplasms, pelvic prosthesis, pelvic reconstruction. Correspondence Dr Qing Dong Shao, Department of Orthopedics, PLA Fourth Fifty-Five Hospital (455 Hospital), No. 338 West Huaihai Road, Changning District, Shanghai 200052, China. Email: [email protected] Q. D. Shao MD, MS; X. Yan MD, MS; J. Y. Sun MD, PhD; T. M. Xu MD, PhD. Accepted for publication 16 September 2014. doi: 10.1111/ans.12895
Abstract Background: Hemipelvectomy is a major operation with significant risks including infection, prosthesis failure and fracture. This systematic review was designed to review the functional outcomes, oncologic outcomes and complications in patients who received internal hemipelvectomy and pelvic reconstruction for primary pelvic tumour. Methods: Searches on MEDLINE, the Cochrane Library, Embase and Google Scholar were performed to locate studies involving patients receiving internal hemipelvectomy and pelvic reconstruction using a prosthesis, implant or bone graft. All studies were either prospective or retrospective observational studies published in English. Results: This systematic review included 12 studies from 1990 to 2011 involving 217 patients from 5 to 77 years of age who had received follow-up for a period from 3 weeks to 15 years. Among the 12 studies, the mortality rate, disease-free rate and incidence of local recurrence were 10–69.2, 23.1–90.0 and 9.1–41.7%, respectively. The post-operative Musculoskeletal Tumor Society (MSTS) functional score ranged from 50 to 70 in the more recent studies. Compared with prostheses and other implants, patients who received allografts had the highest post-operative function, as shown by their MSTS scores, but also had a greater incidence of post-operative infection. On the other hand, the prosthesis group was associated with the highest percentage of fracture and dislocations, as well as other significant complications. Conclusion: This comprehensive review provided informative details regarding the goals, outcomes and complications associated with this procedure and underscored the need for further investigation into the various surgical approaches currently available.
Introduction Pelvic tumours are difficult and challenging to treat due to the complexity of the bony anatomy and the proximity to the bladder, rectum and neurovascular structures. The primary pelvic tumour must be completely removed,1,2 which involves a series of complex surgeries. This often includes excising large amounts of the affected innominate bone and large areas of tissue. There is a 50–80% chance of complications following hemipelvectomy.3,4 In such cases, surgeons have the choice of external or internal hemipelvectomy. External hemipelvectomy is used for tumours that cannot be removed by limb-sparing procedures. External hemipelvectomy involves amputation of the lower limb as well as the pelvis on the affected side. Although amputation can achieve a safe and wide © 2014 Royal Australasian College of Surgeons
resection margin, limb-sparing internal hemipelvectomy with reconstruction of the pelvis is a standard treatment that preserves the patient’s ability to walk and decreases cosmetic and psychological side effects.5 With internal hemipelvectomy, the pelvis is reconstructed with one of a variety of techniques, or it is left unreconstructed and no prosthetic device is surgically implanted. Due to advances in prostheses and multimodal treatment plans, leading to prolonged patient survival, limb-sparing procedures are usually the treatment of choice. However, a limb-sparing internal hemipelvectomy is also associated with complications such as infection.6–8 When internal hemipelvectomy is selected, options for reconstruction include bone grafting or use of a medical implant or a custom-made prosthesis. Some approaches include use of a saddle prosthesis or allografts/prosthetic composite (a total hip or ANZ J Surg 85 (2015) 553–560
554
endoprosthesis).9,10 When no reconstruction is undertaken, the patient is said to have a ‘flail hip’. The disadvantage of the flail hip method is that it results in a larger leg-length discrepancy compared with other methods;11 however, this is also a very common complication even when reconstruction is performed. The use of shoe lifts may help avoid complications associated with reconstruction. The goal of reconstruction is to give the patient a stable, functional hip joint and to restore leg length and quality of life. Although internal hemipelvectomy was performed without reconstruction during the 1970s and 1980s, many newer reconstructive options for patients are now available, including arthrodesis, pseudarthrosis, an allograft/prosthetic composite, insertion of a saddle prosthesis12 or a custom-made implant.13 Because of the extensive surgery and reconstruction required, patients also face the risk of post-operative infection, pain and failure of the implanted devices. Even for those with successful surgery, long-term rehabilitation awaits. Patients will need help learning to become independent with transfers, mobility, feeding, grooming and using the toilet, for example. Patients and their core health care team also need to know that the likelihood of being functionally independent at discharge is low. However, with time, practice and therapy, many people can become independent and are able to perform most functions of everyday life.14 Balancing the benefits and complications from internal hemipelvectomy remains a real challenge. Thus, we performed a systematic review to study the functional outcomes, oncologic outcomes and complications of internal hemipelvectomy with reconstruction in patients with primary pelvic tumours.
Shao et al.
Fig. 1. Flow diagram of study selection.
Methods Search strategy Using the keywords pelvic neoplasms, hemipelvectomy, pelvic reconstruction, pelvic prosthesis, bone graft, we searched the following databases: MEDLINE, the Cochrane Library, Embase and Google Scholar up to 31 January 2013. Reference lists of relevant studies were hand-searched by two independent reviewers, who identified the studies by the search strategy. When there was a question or debate about eligibility, a third reviewer was consulted, and a decision was made by all three reviewers. Studies were included when: (i) the patients had primary cancer at the pelvis; (ii) patients had been treated with internal hemipelvectomy; (iii) the study reported a functional outcome with the use of Musculoskeletal Tumor Society (MSTS) functional score; and (iv) the report was published in English. Studies were excluded when: (i) the patients had metastatic cancer at the pelvis; (ii) the interventions did not include internal hemipelvectomy; or (iii) the study lacked information about functional outcomes. A total of 12 studies were selected for the final analysis.
Quality assessment We assessed the quality of each study using an 18-item modified Delphi checklist, which is a validated tool for assessing the quality of an observational study with no control group.15 The checklist was designed by the Delphi panel as questions to be answered by a simple ‘yes and no’.15 This checklist includes quality control measures such as a clearly stated hypothesis, follow-up data, eligibility standards and length of follow-up.
Results From an initial 481 records identified through searching the four databases, 12 studies were selected and included in the final analysis.6,12,13,16–24 Once the full text of each study was reviewed, six studies were excluded for the following reasons: (i) three studies did not report the functional outcomes; (iii) two study involved external hemipelvectomy; and (iii) one study did not provide information for internal hemipelvectomy subgroup. The reasons for exclusion are summarized in our flow chart for study selection shown in Figure 1.
Data extraction For studies matched with criteria, the following information was extracted: the name of the first author, the year of publication, patients’ characteristics, details about intervention and reconstruction, the length of follow-up, cancer recurrence rate, survival condition, functional score and any complications.
Study characteristics As shown in Table 1, these observational studies were conducted from 1990 to 2011. Most involved small numbers of patients (10–27 patients), except for two studies that included more than 40 patients.19,21 A total of 217 patients were analysed in this study. © 2014 Royal Australasian College of Surgeons
© 2014 Royal Australasian College of Surgeons
2011
2010
2010
2006
2005
2005
2002
2001
2001
2000
1997
1990
13
16
21
19
6
17
23
22
24
12
18
20
Sun
Akiyama
Guo
Court
Aljassir
Asavamongkolkul
Ozaki
Langlais
Pant
Renard
Bruns
Guest
NA, not available.
Year
Ref #
First author
Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, pigmented villonodular synovitis, chondroblastoma Chondrosarcoma, Ewing’s sarcoma, osteosarcoma
Chondrosarcoma, osteoblastoma, osteosarcoma, multiple myeloma, synovial sarcoma
Chondrosarcoma, osteosarcoma, Ewing’s sarcoma, plasmacytoma, chondroblastoma Chondrosarcoma, osteosarcoma, malignant fibrous histiocytoma, Ewing’s sarcoma, chondroblastic osteosarcoma
Chondrosarcoma, osteosarcoma, malignant fibrous histiocytoma, Ewing’s sarcoma, malignant giant cell tumour, epithelioid hemangioendothelioma Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, well-differentiated osteosarcoma, malignant giant cell tumour Chondrosarcoma, osteosarcoma, Ewing’s sarcoma
Ewing’s sarcoma, chondrosarcoma, osteosarcoma, giant cell sarcomas, fibrosarcoma, malignant hemangiopericytoma
Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, giant cell bone tumour, fibrosarcoma Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, malignant peripheral nerve sheath tumour, malignant fibrous histiocytoma Chondrosarcoma
Diagnosis
IA + IIA + III (3) IA + IIA + IIIA (1) I + IIA + IIIA (1) II + III (1) IIA + IIIA (2) IIA + III (1) IA + IIA (1)
I + IIA (1) IIA (5) IIA + total femur (1) Partial I + IIA (1) IIA + prox. Femur (2) IIA-IIC
I (2) IA (5) IA + IIA (2) IIA (3) II + III (1)
Acetabulum + iliac wing (7) Total acetabulum (3)
PI-II (5) PI-II-III (4) PII-III (3) PIII (3) Ilium + acetabulum + pubis (8) Acetabulum + pubis (4)
II (1) I + II (8) II + III (23) I + II + III (8) I + II + IV (5) I (23) I + II, partial removal of the acetabulum (10) I + II (4) I + II + III (3) II (7) II + III (20)
I (4) I + IV (6)
NA
Classification of resection
Table 1 Characteristics and summary of the 12 included studies
Allograft
Prosthesis
Prosthesis
Prosthesis; autograft
Allograft
Prosthesis
Autograft
Prosthesis
Allograft
Prosthesis; autograft
Autograft
Prosthesis
Type of reconstruction
Allograft reconstruction
Custom-made alloplastic endoprosthetic pelvic replacement
Super-Girdlestone (4) Iliofemoral arthrodesis (1) Fibular strut grafts (5) Retained bony bridge (2) Reimplantation of autoclaved acetabulum (1) Saddle prosthesis
Computer-aided designed custom-made hemipelvic megaprosthesis Allograft reconstruction
Autogenous fibular bone grafting (2)
Saddle prosthesis
Modular hemipelvic prosthesis (27) Saddle prosthesis (4) Devitalized tumour bone (5) Arthrodesis (3) Amputation (6) Allograft reconstruction, osteosynthesis and arthrodesis
Non-vascularized fibular graft
Computer-aided hemipelvic prosthesis
Detail of reconstructions
10
11
15
13
10
12
13
27
40
45
10
16
Number of patients
Mean: 41.6 (16–62)
Mean: 47.5 (range: 19–72), including secondary pelvic tumour
Mean: 40.9 (range: 12–74)
Mean: 19.2 (range: 5–35)
NA
Mean: 45.5 (25–74)
Mean: 33 (range: 8–56)
Mean: 53 (range 24–76)
Mean: 28 (range: 11–66)
Mean: 41.2 (18–63)
Mean: 39.8 (range: 18–77)
Mean: 27 (range: 13–36)
Age (year)
6/4
NA
8/2
12/1
NA
5/7
7/6
18/9
22/18
26/19
7/3
10/6
Males/ females
Mean: 25 months (range: 7–85 months)
Maximum: 15 years
Maximum 3 years
Mean: 7 years
Mean: 4 years (range:
Internal hemipelvectomy with reconstruction for primary pelvic neoplasm: a systematic review Qing Dong Shao, Xu Yan, Jiu Yi Sun and Tian Ming Xu Department of Orthopedics, PLA Fourth Fifty-Five Hospital (455 Hospital), Shanghai, China
Key words bone graft, hemipelvectomy, pelvic neoplasms, pelvic prosthesis, pelvic reconstruction. Correspondence Dr Qing Dong Shao, Department of Orthopedics, PLA Fourth Fifty-Five Hospital (455 Hospital), No. 338 West Huaihai Road, Changning District, Shanghai 200052, China. Email: [email protected] Q. D. Shao MD, MS; X. Yan MD, MS; J. Y. Sun MD, PhD; T. M. Xu MD, PhD. Accepted for publication 16 September 2014. doi: 10.1111/ans.12895
Abstract Background: Hemipelvectomy is a major operation with significant risks including infection, prosthesis failure and fracture. This systematic review was designed to review the functional outcomes, oncologic outcomes and complications in patients who received internal hemipelvectomy and pelvic reconstruction for primary pelvic tumour. Methods: Searches on MEDLINE, the Cochrane Library, Embase and Google Scholar were performed to locate studies involving patients receiving internal hemipelvectomy and pelvic reconstruction using a prosthesis, implant or bone graft. All studies were either prospective or retrospective observational studies published in English. Results: This systematic review included 12 studies from 1990 to 2011 involving 217 patients from 5 to 77 years of age who had received follow-up for a period from 3 weeks to 15 years. Among the 12 studies, the mortality rate, disease-free rate and incidence of local recurrence were 10–69.2, 23.1–90.0 and 9.1–41.7%, respectively. The post-operative Musculoskeletal Tumor Society (MSTS) functional score ranged from 50 to 70 in the more recent studies. Compared with prostheses and other implants, patients who received allografts had the highest post-operative function, as shown by their MSTS scores, but also had a greater incidence of post-operative infection. On the other hand, the prosthesis group was associated with the highest percentage of fracture and dislocations, as well as other significant complications. Conclusion: This comprehensive review provided informative details regarding the goals, outcomes and complications associated with this procedure and underscored the need for further investigation into the various surgical approaches currently available.
Introduction Pelvic tumours are difficult and challenging to treat due to the complexity of the bony anatomy and the proximity to the bladder, rectum and neurovascular structures. The primary pelvic tumour must be completely removed,1,2 which involves a series of complex surgeries. This often includes excising large amounts of the affected innominate bone and large areas of tissue. There is a 50–80% chance of complications following hemipelvectomy.3,4 In such cases, surgeons have the choice of external or internal hemipelvectomy. External hemipelvectomy is used for tumours that cannot be removed by limb-sparing procedures. External hemipelvectomy involves amputation of the lower limb as well as the pelvis on the affected side. Although amputation can achieve a safe and wide © 2014 Royal Australasian College of Surgeons
resection margin, limb-sparing internal hemipelvectomy with reconstruction of the pelvis is a standard treatment that preserves the patient’s ability to walk and decreases cosmetic and psychological side effects.5 With internal hemipelvectomy, the pelvis is reconstructed with one of a variety of techniques, or it is left unreconstructed and no prosthetic device is surgically implanted. Due to advances in prostheses and multimodal treatment plans, leading to prolonged patient survival, limb-sparing procedures are usually the treatment of choice. However, a limb-sparing internal hemipelvectomy is also associated with complications such as infection.6–8 When internal hemipelvectomy is selected, options for reconstruction include bone grafting or use of a medical implant or a custom-made prosthesis. Some approaches include use of a saddle prosthesis or allografts/prosthetic composite (a total hip or ANZ J Surg 85 (2015) 553–560
554
endoprosthesis).9,10 When no reconstruction is undertaken, the patient is said to have a ‘flail hip’. The disadvantage of the flail hip method is that it results in a larger leg-length discrepancy compared with other methods;11 however, this is also a very common complication even when reconstruction is performed. The use of shoe lifts may help avoid complications associated with reconstruction. The goal of reconstruction is to give the patient a stable, functional hip joint and to restore leg length and quality of life. Although internal hemipelvectomy was performed without reconstruction during the 1970s and 1980s, many newer reconstructive options for patients are now available, including arthrodesis, pseudarthrosis, an allograft/prosthetic composite, insertion of a saddle prosthesis12 or a custom-made implant.13 Because of the extensive surgery and reconstruction required, patients also face the risk of post-operative infection, pain and failure of the implanted devices. Even for those with successful surgery, long-term rehabilitation awaits. Patients will need help learning to become independent with transfers, mobility, feeding, grooming and using the toilet, for example. Patients and their core health care team also need to know that the likelihood of being functionally independent at discharge is low. However, with time, practice and therapy, many people can become independent and are able to perform most functions of everyday life.14 Balancing the benefits and complications from internal hemipelvectomy remains a real challenge. Thus, we performed a systematic review to study the functional outcomes, oncologic outcomes and complications of internal hemipelvectomy with reconstruction in patients with primary pelvic tumours.
Shao et al.
Fig. 1. Flow diagram of study selection.
Methods Search strategy Using the keywords pelvic neoplasms, hemipelvectomy, pelvic reconstruction, pelvic prosthesis, bone graft, we searched the following databases: MEDLINE, the Cochrane Library, Embase and Google Scholar up to 31 January 2013. Reference lists of relevant studies were hand-searched by two independent reviewers, who identified the studies by the search strategy. When there was a question or debate about eligibility, a third reviewer was consulted, and a decision was made by all three reviewers. Studies were included when: (i) the patients had primary cancer at the pelvis; (ii) patients had been treated with internal hemipelvectomy; (iii) the study reported a functional outcome with the use of Musculoskeletal Tumor Society (MSTS) functional score; and (iv) the report was published in English. Studies were excluded when: (i) the patients had metastatic cancer at the pelvis; (ii) the interventions did not include internal hemipelvectomy; or (iii) the study lacked information about functional outcomes. A total of 12 studies were selected for the final analysis.
Quality assessment We assessed the quality of each study using an 18-item modified Delphi checklist, which is a validated tool for assessing the quality of an observational study with no control group.15 The checklist was designed by the Delphi panel as questions to be answered by a simple ‘yes and no’.15 This checklist includes quality control measures such as a clearly stated hypothesis, follow-up data, eligibility standards and length of follow-up.
Results From an initial 481 records identified through searching the four databases, 12 studies were selected and included in the final analysis.6,12,13,16–24 Once the full text of each study was reviewed, six studies were excluded for the following reasons: (i) three studies did not report the functional outcomes; (iii) two study involved external hemipelvectomy; and (iii) one study did not provide information for internal hemipelvectomy subgroup. The reasons for exclusion are summarized in our flow chart for study selection shown in Figure 1.
Data extraction For studies matched with criteria, the following information was extracted: the name of the first author, the year of publication, patients’ characteristics, details about intervention and reconstruction, the length of follow-up, cancer recurrence rate, survival condition, functional score and any complications.
Study characteristics As shown in Table 1, these observational studies were conducted from 1990 to 2011. Most involved small numbers of patients (10–27 patients), except for two studies that included more than 40 patients.19,21 A total of 217 patients were analysed in this study. © 2014 Royal Australasian College of Surgeons
© 2014 Royal Australasian College of Surgeons
2011
2010
2010
2006
2005
2005
2002
2001
2001
2000
1997
1990
13
16
21
19
6
17
23
22
24
12
18
20
Sun
Akiyama
Guo
Court
Aljassir
Asavamongkolkul
Ozaki
Langlais
Pant
Renard
Bruns
Guest
NA, not available.
Year
Ref #
First author
Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, pigmented villonodular synovitis, chondroblastoma Chondrosarcoma, Ewing’s sarcoma, osteosarcoma
Chondrosarcoma, osteoblastoma, osteosarcoma, multiple myeloma, synovial sarcoma
Chondrosarcoma, osteosarcoma, Ewing’s sarcoma, plasmacytoma, chondroblastoma Chondrosarcoma, osteosarcoma, malignant fibrous histiocytoma, Ewing’s sarcoma, chondroblastic osteosarcoma
Chondrosarcoma, osteosarcoma, malignant fibrous histiocytoma, Ewing’s sarcoma, malignant giant cell tumour, epithelioid hemangioendothelioma Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, well-differentiated osteosarcoma, malignant giant cell tumour Chondrosarcoma, osteosarcoma, Ewing’s sarcoma
Ewing’s sarcoma, chondrosarcoma, osteosarcoma, giant cell sarcomas, fibrosarcoma, malignant hemangiopericytoma
Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, giant cell bone tumour, fibrosarcoma Chondrosarcoma, Ewing’s sarcoma, osteosarcoma, malignant peripheral nerve sheath tumour, malignant fibrous histiocytoma Chondrosarcoma
Diagnosis
IA + IIA + III (3) IA + IIA + IIIA (1) I + IIA + IIIA (1) II + III (1) IIA + IIIA (2) IIA + III (1) IA + IIA (1)
I + IIA (1) IIA (5) IIA + total femur (1) Partial I + IIA (1) IIA + prox. Femur (2) IIA-IIC
I (2) IA (5) IA + IIA (2) IIA (3) II + III (1)
Acetabulum + iliac wing (7) Total acetabulum (3)
PI-II (5) PI-II-III (4) PII-III (3) PIII (3) Ilium + acetabulum + pubis (8) Acetabulum + pubis (4)
II (1) I + II (8) II + III (23) I + II + III (8) I + II + IV (5) I (23) I + II, partial removal of the acetabulum (10) I + II (4) I + II + III (3) II (7) II + III (20)
I (4) I + IV (6)
NA
Classification of resection
Table 1 Characteristics and summary of the 12 included studies
Allograft
Prosthesis
Prosthesis
Prosthesis; autograft
Allograft
Prosthesis
Autograft
Prosthesis
Allograft
Prosthesis; autograft
Autograft
Prosthesis
Type of reconstruction
Allograft reconstruction
Custom-made alloplastic endoprosthetic pelvic replacement
Super-Girdlestone (4) Iliofemoral arthrodesis (1) Fibular strut grafts (5) Retained bony bridge (2) Reimplantation of autoclaved acetabulum (1) Saddle prosthesis
Computer-aided designed custom-made hemipelvic megaprosthesis Allograft reconstruction
Autogenous fibular bone grafting (2)
Saddle prosthesis
Modular hemipelvic prosthesis (27) Saddle prosthesis (4) Devitalized tumour bone (5) Arthrodesis (3) Amputation (6) Allograft reconstruction, osteosynthesis and arthrodesis
Non-vascularized fibular graft
Computer-aided hemipelvic prosthesis
Detail of reconstructions
10
11
15
13
10
12
13
27
40
45
10
16
Number of patients
Mean: 41.6 (16–62)
Mean: 47.5 (range: 19–72), including secondary pelvic tumour
Mean: 40.9 (range: 12–74)
Mean: 19.2 (range: 5–35)
NA
Mean: 45.5 (25–74)
Mean: 33 (range: 8–56)
Mean: 53 (range 24–76)
Mean: 28 (range: 11–66)
Mean: 41.2 (18–63)
Mean: 39.8 (range: 18–77)
Mean: 27 (range: 13–36)
Age (year)
6/4
NA
8/2
12/1
NA
5/7
7/6
18/9
22/18
26/19
7/3
10/6
Males/ females
Mean: 25 months (range: 7–85 months)
Maximum: 15 years
Maximum 3 years
Mean: 7 years
Mean: 4 years (range:
