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.