The purpose of this study is to compare functional results of hemipelvectomy and internal hemipelvectomy following resection of pelvic tumours. The emotional acceptance of such surgery is also examined. From 1998 to 2003, 19 male and 13 female patients, aged from 6 to 76 years, underwent hemipelvectomy, and 12 male and seven female patients, aged from 13 to 65 years, underwent internal hemipelvectomy. In the series as a whole, follow-up ranged from 1 to 156 months. Five patients with external hemipelvectomy, six with internal hemipelvectomy and one who underwent internal hemipelvectomy followed by external hemipelvectomy were evaluated functionally, clinically and psychologically. Patients expressed emotional concern about body image and mobility. Psychosocial adjustment was difficult for all patients, but some were able to overcome their difficulties more easily than others. Patients with internal hemipelvectomy rather than external hemipelvectomy had more difficulty adjusting emotionally. The site of the tumour and morbidity rates, which remain high when limb-sparing surgery is performed for pelvic tumours, are important considerations when deciding upon the type of surgery. Patients and their families need extensive preoperative psychological preparation and postoperative psychotherapy is imperative

Introduction and aims. After internal hemipelvectomy for malignant pelvic tumors, pelvic reconstruction is necessary for eventual weight bearing and ambulation. Non-vascularised, fibular grafts (NVFG) offer fast, and stable reconstruction, post- modified Enneking's type I and I/IV resection. This study aimed to evaluate the success of graft union and patient function after NVFG reconstruction. Methods. From 1996 to 2009, 10 NVFG pelvic reconstructions were performed after internal hemipelvectomy in four cases of chondrosarcoma, three of Ewing's sarcoma, and single cases of osteosarcoma, malignant peripheral nerve sheath tumour, and malignant fibrous histiocytoma. A key indication for internal hemipelvectomy was sciatic notch preservation confirmed by preoperative MRI. Operation time and complications were recorded. The mean follow-up was 31.1 months (range: 5 to 56), and lower limb function was assessed using the Musculoskeletal Tumour Society scoring system. Plain radiographs and/or computer tomography were used to determine the presence or absence of NVFG union. Results. The mean operation time was four hours and 56 mins, with no major intraoperative complications and partial wound break-down in only one patient. The NVFG united successfully in all patients, with a mean union time of 7.3 months. Post-operative deep infection did not occur in any case. Seven patients were eventually able to ambulate without a cane, and overall, the average function rating percentage was 75.4%. Recurrent tumour occurred in two cases following primary resection. Death from tumour-related disease occurred in one of the ten cases. Conclusions. NVFG is a stable and reliable pelvic reconstruction method after type I and type I/IV hemipelvectomy. Reliability may be linked to preservation of graft periosteum, and careful patient selection, limited to those with an intact sciatic notch. Furthermore, the relatively short operative time required should help minimise deep infection

Presentation of two cases of pelvic periacetabular sarcoma, which were treated with wide resection of the tumor, pelvic reconstruction and lower limb salvage. Two patients, one male 23 y.o. with chondrosarcoma and one female 75 y.o. with chondroblastic osteosarcoma, were treated in our clinic. Both tumors were stage II according to Enneking’s classification. Both tumors were treated with Enneking type II internal hemipelvectomy due to their periacetabular localization. After wide resection of tumors, pelvic deficit was reconstructed with allograft, which was internally fixated, and total hip replacement with constrained prosthesis. Clinical evaluation showed absence of pain and satisfactory function of the limb. Imaging evaluation with x-ray, 3D-scan kai MRI showed satisfactory position and condition of allograft and internal fixation without evidence of loosening. Non weight bearing mobilization commenced 3 weeks postoperatively. Internal hemipelvectomy requires precise preoperative planning and surgical knowledge because it is technically demanding due to complex structure of the pelvis, the great number of muscular attachments and the presence of important vessels, nerves and pelvic viscera. Wide pelvic resection and reconstruction with allograft for periacetabular sarcomas is a challenging procedure, which offers the opportunity of limb salvage associated with functional outcome

A rare case of malignant transformation of fibrous dysplasia to chondrosarcoma involving the pelvis, treated by hemipelvectomy, was described by our team in a published case report. Twenty-four years later, the patient remains recurrence-free, with a good functional outcome that allows him to be independent in everyday activities and work in full time employment. Functional outcome following hemipelvectomy for pelvic malignancy is an evolving topic, as improved imaging and surgical techniques result in earlier diagnosis and a better overall prognosis. Sarcomas involving the pelvis still represent a challenging topic for surgeons. During the last twenty-four years, there have been some advances in the limb- salvage treatment of pelvic tumours. An internal hemipelvectomy is currently considered to be a reasonable treatment option, with good functional outcomes and achievement of satisfactory tumour clearance margins, in well- selected cases. In all cases however, the main focus should be in the adequate resection of the lesion, followed by restoration of maintenance of stability. We report a fascinating case of a patient who underwent internal hemipelvectomy without reconstruction for chondrosarcomatous transformation of pelvic fibrous dysplasia, with emphasis on the clear surgical resection margins and disease-free status of the patient and satisfactory functional outcome. We support that internal hemipelvectomy is an acceptable treatment option in well- selected cases and can achieve clear tumour resection margins, resulting in long term disease-free results, and a good limb- salvage functional outcome. We believe that joint stability in this patient is mainly a result of preservation of the adductor muscle group, which prevents the hip joint from upward migration and allows the patient to use his left leg for walking

Purpose: Resection of pelvic sarcoma with limb preservation (internal hemipelvectomy) is a major undertaking. Resection requires large areas of soft-tissue to be removed. Because of wound complications, we manage these defects with immediate tissue transfer (ITT) at the time of resection when a large defect is anticipated. This study compares the outcomes of ITT with primary wound closure (PWC).

Method: Twenty patients undergoing 22 separate procedures (1995–2007) were identified in our prospectively maintained database. Demographics, tumour type, operative data and complications, and functional scores (MSTS-1993, TESS) were collected.

Results: Twelve defects were managed with ITT, nine with pedicled myocutaneous vertical rectus abdominis (VRAM) flaps (one received double VRAM flaps due to the large defect), two with tensor fascia lata (TFL) rotation flaps (one augmented by local V-Y advancement, the other with gluteus maximus rotation flap) and one received latissimus dorsi free tissue transfer. Four wound complications necessitated operative intervention in this group: two debrided VRAM flaps went on to heal and the two TFL flaps required revision: one to VRAM flap and the other to a latissimus dorsi free flap which ultimately suffered chronic infection and hindquarter amputation was performed. Ten defects were managed with PWC, and 5 wound complications occurred, all five suffered infection, one developed hematoma and one dehisced. One wound resolved with debridement, two healed after revision to pedicled gracilis and gluteus maximus myocutaneous flaps. Two patients were converted to hindquarter amputation due to chronic infection. Functional scores were collected on 8 of 12 living patients, at time of writing. The mean TESS scores were 83 and 73 in the ITT and PWC groups. Five patients in the ITT and 3 in the PWC group were deceased.

Conclusion: Soft-tissue closure following pelvic sarcoma resection remains a difficult challenge, and our experience reflects that. There were fewer wound complications (33% v 50%) and slightly better function with ITT than PWC, but this was not statistically significant due to the small size of our study. Although small, this study suggests ITT should be considered whenever a large soft tissue defect is anticipated.

Purpose: We report a series of patients with malignant tumours of the pelvis that had a tissue expander inserted in the pelvis to facilitate radical radiotherapy, and report functional outcomes following treatment. Introduction: Surgery for malignant tumours affecting the pelvis is challenging. Some tumours are suitable for internal hemipelvectomy and reconstruction, some require hindquarter amputation and some are inoperable. Overall prognosis is poor with high morbidity and mortality rates. There may be a place for alternative treatment with the insertion of pelvic spacers to facilitate radical radiotherapy. This is indicated in patients who have an inoperable tumour, who decline amputation, or who had an internal hemipelvectomy with close margins and high risk of local recurrence. Methods & Results: We performed a retrospective review of all patients who presented with a malignant tumour of the pelvis and who underwent an insertion of a pelvic spacer followed by local high dose radiotherapy. Available patients were followed up and evaluated using the Musculoskeletal Society Tumour Score (MSTS) and the Toronto Extremity Salvage Score (TESS). There were ten patients; 5 had Ewing’s sarcoma, 3 had osteosarcoma, 1 had spindle cell sarcoma and 1 had alveolar soft part sarcoma. 4 patients had metastases on presentation. The average age was 30 years (14 to 56 years), and average follow-up was 15 months (12 to 24 months). 4 patients died and 6 are still alive. There were no surgical complications. The average length of hospital stay was 6 days (2 to 10 days). Patients averaged an MSTS score of 63% and a TESS of 67%. Conclusion: Radical radiotherapy after spacer insertion offers an alternative to morbid surgery and is associated with good functional outcomes

Introduction. The aim of this study is to evaluate the functional and oncological outcome of extracorporeally irradiated autografts as a method of pelvic reconstruction after internal hemipelvectomy. Methods. The study included fifteen patients with primary malignant bone tumours of the pelvis. There were 10 males and 5 females with a mean age of 21.5 years (range, 8 to 46 years). Six patients had Ewing's sarcoma, six osteosarcoma, and three chondrosarcoma. Results. At a mean follow-up of 52.3 months (range, 4 to 180 months), five patients were free from disease, nine had died with metastatic disease, while one patient was alive with pulmonary metastasis. Local recurrence occurred in three patients (20%) and all eventually died of disease progression. Two patients developed deep infection which necessitated graft removal. The mean MSTS functional score in those thirteen patients who could be followed up for at least 12 months was 77% (range, 60-87%). According to Mankin's allograft functional grading system, there were five excellent, five good, one fair result and two failures. Discussion. Periacetabular reconstruction after tumour resection is a real challenge to orthopaedic surgeons. There is no ideal method of reconstruction and the decision needs to be individualized. Extracorporeal irradiation and re-implantation of bone is a valid method of reconstruction after pelvic resections with acceptable morbidity rate and functional outcome that compares favourably to other available reconstructive techniques

Adequate resection of malignant osseous tumors of the pelvis within wide margins is demanding surgery. To avoid disabling hemipelvectomies, during the seventies of the last century internal hemipelvectomy combined with a partial pelvic replacement had become a new surgical and meanwhile standard procedure. To achieve adequate reconstructions of the osseous pelvis custom-made replacements were recommended. In the very early stages of this type of surgical procedure using megapros-theses, individual pelvic models were manufactured but, until recently, little is known about the accuracy of such models. Thus, it was the aim of this retrospective study to evaluate this. We analysed the charts of 24 patients (25 pelvic models) for whom an individual model of the osseous pelvis had been constructed to manufacture such a tool and to enable the surgeon a better intraoperative orientation. Two patients refused surgery. Thus, in 23 patients surgical resection of parts of the bony pelvis was performed followed by either a partial pelvic replacement (13 x), hip transposition procedure (5 x), ilio-sacral resection (4 x) or revision surgery (exchange of a partial pelvic replacement). In all patient who received a partial pelvic replacement, the fit of the replacement was optimal, in none of them a major unplanned resection was necessary. The same was observed in patients who received a hip transposition procedure or an ilio-sacral resection. Oncologically, in most of the patients we achieved wide resection margins (14 x). In only 5 patients the margins were marginal (4x) or intralesionsal (1 x). In two cases the aim was a palliative resection because of a metastatic disease (1x) or benign entity (1 x). Thus, pelvic models are helpful tools to planning the manufacture of partial pelvic replacements and ensuring optimal osseous resection of the involved bone. Further attempts have to be made to evaluate the aim of navigational techniques regarding improvement of the accuracy of the osseous and the soft tissue resection

Reconstruction following internal hemipelvectomy for bone tumors remains a major surgical challenge. Most of the cases are considered not suitable for reconstruction because of high complication occurrence. Allografts coupled with standard prosthesis is a reliable method of reconstruction. 26 patients received a McMinn stemmed cup (Link, Germany) after periacetabular tumor resection from February 1999 to 2006. In 18 patients the reconstruction followed resection of the acetabular area while in other 8 an extrarticular resection of the proximal femur was performed. In 21 cases a stemmed acetabular cup were associated with massive bone allograft. There were 13 female and 13 male with a mean age of 41 years (13 to 70). Average follow-up was 45 months (7 to 105). Six patients were affected by local recurrence of the tumour and five underwent hindquarter amputation. In 4 of them the index surgery followed a previous recurrence of the tumour. Finally 6 patients died for related causes within 2 years. All the other 20 have been followed clinically and radiographically for a minimum of 24 months. Deep infection occurred in one case, there were no cases of dislocation. Radiolucency at the prosthesis-bone interface was observed in 3 cases, 2 patients had proximal migration < of 20 mm. Only one patient was treated for aseptic loosening because of incorrect initial position of the implant. The iliac osteotomy was consolidated in all cases, while a delayed union was frequently observed in the pubic osteotomy, however without compromise the stability of implant. Functional result were evaluated according to the MSTS system and this showed 65% of excellent or good clinical results. The procedure requires appropriate patient selection, accurate preoperative planning, meticulous selection and preparation of allograft. Usually artificial ligaments are applied to reduce hip instability, however, this type of reconstruction do not require complex fixation, thus reducing surgical time and early complications

Introduction: Pelvic and acetabular reconstruction following tumor resections are often difficult and fraught with complications. This is the first report of a reconstruction utilizing sacral implantation of an acetabular component, a relatively simple procedure. Materials and Methods: A 74 year-old man developed recurrent low-grade chondrosarcoma in his ilium. Prior resections had included total hip reconstruction with massive cemented acetabular components. A combined Type I and II internal hemipelvectomy with endoprosthetic reconstruction were performed. Following resection, his sacrum and a small fragment of remaining ilium at the sacroiliac joint was reamed to accept a 48 mm porous coated acetabular component. It was press- fit into place and further secured with two central and three rim screws. A constrained cup liner was used. A proximal femoral endoprosthesis was constructed from a commercially available modular oncology system. Additional resection of the superior and inferior pubic ramie was required to minimize the likelihood of endoprosthetic impingement and leverage-induced dislocation. A soft tissue reconstruction of the abductors was accomplished. Results: He remains free of recurrence 15 months post-operative. He ambulates full weight bearing with crutches. His leg is neurovascularly intact and he is pleased with his results. A videotape, demonstrating his gait, will be shown. Discussion: The author knows of one similar reconstruction that was performed at another center (unpublished data). That other patient suffered acetabular component dislodgement. The intraoperative leverage-induced dislocation of the hip was the important determination. Pubic rami resection may be required to prevent femoral impingement and instability. The use of multiple fixation screws also improved component fixation. Conclusion: Placement of a well fixed, constrained, acetab-ular component into a retained sacrum at the level of the SI joint provides an alternative limb salvage technique

Introduction: Infection following major orthopaedic oncological surgery is a serious complication and every precaution should be taken to avoid it. One potential source of infection is the biopsy procedure, particularly when is carried out of a referring centre. In fact up to 30 per cent of patients with soft tissues problems following a biopsy is reported. As an infected biopsy may make subsequent limb preservation surgery impractical, the greatest care should be taken in carrying out the biopsy. The implantation of foreign materials (prostheses, grafts, acrilic cement, metallic devices, etc) as the duration of the surgical procedure, intraoperative bleeding, possible deep haematomas, presence of drains, increase the risk of infection. Also the importance of haematogenous spread from other sites of infection to joint pros-thesis is well estabilished. Materials and methods: In this paper the Authors present their experience regarding septic complications after orthopaedic oncologie surgery. From 1988 to 2002, 143 patients underwent a major surgery for the treatment of skeletal neoplasms (wide resection and reconstruction employing modular or composite prostheses, osteoarticular or intercalary allografts, acrylic cement and osteosynthesis devices, major spinal surgery, internal hemipelvectomy, etc). Results: The patients were followed-up to detect the presence of a septic complication. Also patient’s files were revised to evaluate paramethers related to infection as bleeding, duration of surgery, postoperative fever, neutropenia, ESR and CRP, antibiotic prophylaxis, etc. The overall infection rate was approximately to 15 per cent. Conclusions: Immunosuppression from previous chemotherapy may predispose the patient to infection which may be occult, but which must be diligently sought. It has to be also emphasized that if at any stage the patient has had local radiotherapy, the tissues may be fibrosed and avascular and unable to combat local infection effectively. The Authors retain that the infection after major orthopaedic oncologie surgery could represent a serious threat to the implant and to the limb. The importance of meticolous asepsis practised at every stage has to be emphasized, together with prolonged use of prophylactic antibiotic, specially in immunosuppressed patients or chemotherapy

Nowadays 80% of patients with bone sarcomas can benefit from limb salvage. Their disease-free life expectancy is not jeopardised by conservative surgery as long as safe margins are obtained. For this reason, the oncological result relies on the accuracy of pre-operative and per-operative surgical measurements. Pre-operative evaluation of tumours is now quite accurate with digital margins (computed tomography, MNR, digital angiography). However, surgeons are still using centimeters or conventional radiographs with their own technical limitations for per-operative evaluation. A more accurate technique is needed. The system is composed of three components: 1) a color, graphic computer workstation with software to calculate and present the location of the surgical instrument on a three-dimensional, reconstructed bone image, 2) a complete set of hand-held instruments containing infrared emitters, 3) an infrared receiver linked to the work station. This measuring system enables determination of the position and incidence of a surgical instrument in real time during surgery, with an accuracy of less than one mm. The system requires four steps: 1) recording data with C.T., N.M.R. or angiography, 2) creating a three-dimensional image displayed on the computer screen for preoperative simulation of a virtual operation, 3) recording the very important anatomical points of the patient and optimal incidences of the surgical instruments, 4) preoperative location of surgical instruments and control of their location on bone. This system is very useful for resection of bone tumours when the conventional location is uncertain (innonimate bone, rib), when very sharp accuracy is needed to preserve the growth plate of the distal femur in young children, and to avoid medullary damage in a spinal tumour. The frameless stereotactic device is also very accurate in the reconstructive phase of limb salvage. After an internal hemipelvectomy, the device permits localisation of the acetabular prosthesis in the precise location before resection. In our practice, the accuracy of the video guiding system is always within two mm as compared to conventional measurements usually between one or two cm for long bones and three to five cm for innominate bone. The use of a video guidance system is very beneficial for limb salvage surgery for pelvic bone tumours

Nowadays 80% of patients with bone sarcomas can benefit from limb salvage. Their disease-free life expectancy is not jeopardised by conservative surgery as long as safe margins are obtained. For this reason, the oncological result relies on the accuracy of pre-operative and per-operative surgical measurements. Pre-operative evaluation of tumours is now quite accurate with digital margins (computed tomography, MNR, digital angiography). However, surgeons are still using centimeters or conventional radiographs with their own technical limitations for per-operative evaluation. A more accurate technique is needed. The system is composed of three components: 1) a color, graphic computer workstation with software to calculate and present the location of the surgical instrument on a three-dimensional, reconstructed bone image, 2) a complete set of hand-held instruments containing infrared emitters, 3) an infrared receiver linked to the work station. This measuring system enables determination of the position and incidence of a surgical instrument in real time during surgery, with an accuracy of less than one mm. The system requires four steps: 1) recording data with C.T., N.M.R. or angiography, 2) creating a three-dimensional image displayed on the computer screen for preoperative simulation of a virtual operation, 3) recording the very important anatomical points of the patient and optimal incidences of the surgical instruments, 4) preoperative location of surgical instruments and control of their location on bone. This system is very useful for resection of bone tumours when the conventional location is uncertain (innonimate bone, rib), when very sharp accuracy is needed to preserve the growth plate of the distal femur in young children, and to avoid medullary damage in a spinal tumour. The frameless stereotactic device is also very accurate in the reconstructive phase of limb salvage. After an internal hemipelvectomy, the device permits localisation of the acetabular prosthesis in the precise location before resection. In our practice, the accuracy of the video guiding system is always within two mm as compared to conventional measurements usually between one or two cm for long bones and three to five cm for innominate bone. The use of a video guidance system is very beneficial for limb salvage surgery for pelvic bone tumours

Aims

Custom triflange acetabular components (CTACs) play an important role in reconstructive orthopaedic surgery, particularly in revision total hip arthroplasty (rTHA) and pelvic tumour resection procedures. Accurate CTAC positioning is essential to successful surgical outcomes. While prior studies have explored CTAC positioning in rTHA, research focusing on tumour cases and implant flange positioning precision remains limited. Additionally, the impact of intraoperative navigation on positioning accuracy warrants further investigation. This study assesses CTAC positioning accuracy in tumour resection and rTHA cases, focusing on the differences between preoperative planning and postoperative implant positions.