The application of 3D-printing technology in pelvic bone tumor surgery
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Keywords:
3d printed
Hemipelvectomy
Pelvic tumor
Objective To discuss the techniques of tumor resection, pelvic reconstruction and postoperative management by reviewing the patients with malignant pelvic tumors in recent years. Methods 76 patients with primary malignant pelvic tumors were treated operatively between July 1997 and July 2003. The series comprised 47 males and 29 females. 31 cases were diagnosed as chondrosarcoma, 15 as Ewing sarcoma, 7 as osteosarcoma, 3 as lymphoma, 3 as malignant fibrohistiocytoma (MFH), 1 as hemangiopericytoma, 2 as myeloma, 13 as giant cell tumor(GCT). According to Enneking's division, the most common region of the primary pelvic tumor involved was region Ⅱ (51 cases), followed by region Ⅰ (16 cases) and region Ⅲ (9 cases). 16 cases were reconstructed with threaded pins and cement after resection of the ilium. 9 patients had local resection of pubis and ischium. 21 patients had hemipelvectomy. Among 30 patients with periacetabular tumors, 8 were reconstructed with hemipelvic prosthesis, 7 with saddle prosthesis, 6 with replantation of cauterized tumor bone and total hip arthroplasty, 9 with cemented total hip replacement after curettage of lesion. Results After 16 months to 6 years follow-up, among the 21 patients with hemipelvectomy, 4 patients had local relapse because the sacrum invaded by the tumors. 7 of 25 patients with lesions in regionⅠ or region Ⅲ had local relapse postoperatively due to the marginal incision to the acetabula. Among the 21 patients who had tumor resection and reconstruction in region Ⅱ, 4 had local relapse, 3 of which reconstructed with cauterized hemipelvis. As for functional recovery, all of the 25 patients with lesions in region Ⅰand region Ⅲcould walk postoperatively without assistance of a cane. 21 patients with acetabular reconstruction after resection of lesions in region Ⅱ could sit and stand normally and walked with a cane, some of them even had normal gait. Conclusion The major principle of treatment for primary pelvic tumor is that en bloc resection, only then the functional reconstruction of pelvic ring can be considered. Operators should be acquainted with advantages and shortcomings of different reconstructive methods of acetabulum to prevent the complications.
Hemipelvectomy
Ischium
Curettage
Pelvic tumor
Primary bone
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Limb sparing surgery has replaced the amputation surgery in the treatment of limb sarcomas. Recurrent or persistent disease constitutes a major problem. Local symptoms such as agonizing pain, fractures, tumor fungation, inability to walk and inability to maintain daily activities, further impair the patient's quality of life. In this clinical set-up palliative amputation should be considered. Eighteen patients with soft-tissue or bone sarcomas and 3 patients with metastatic carcinoma underwent palliative major amputation. Hemipelvectomy was performed in 3 patients, hip disarticulation in 10, knee disarticulation or below-knee amputation in 3 patients, shoulder disarticulation in one patient and forequarter amputation in 4 patients. Local control of the disease and pain and improvement of the performance status were observed in 19 evaluable patients. The mobility was restored in 15 patients with lower limb surgery. The median survival following the procedure was 9 months. There was only one case of immediate post-operative death. Severe phantom pain was not reported by any of the patients. Quality of life was reported to be improved by two-thirds of the patients. To conclude, we have found palliative major amputation surgery worth performing in low-performance status cancer patients with locally advanced disease.
Hemipelvectomy
Disarticulation
Phantom pain
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The amputation is represented by the deliberate surgical removal of a limb, limb segment, or body part. From an etiological point of view, the amputations are caused by chronic vascular diseases, diabetes, tumors and trauma. At the lower limbs, the amputation can be performed at the following levels: finger amputation, transmetatarsal amputation, Lisfranc amputation, Chopart amputation, Syme amputation, transtibial amputation, rotationplasty, knee disarticulation, transfemoral amputation, hip disarticulation and hemipelvectomy. The level of the amputation is determined by factors such as: at the amputations caused by a trauma, the viable tissue determines the level, and in the case of vascular diseases with infection, the level is determined by the unaffected vascular area. The transfemoral amputation is performed through the femoral and thigh muscles and covers almost 85% of all amputations. At patient with transfemoral amputation, there is only a 25% success from the prosthesis use. From a therapeutic point of view, the patient with amputation is approached by an interdisciplinary team that can be consisted of: doctor, nurse, psychologist, physiotherapist, orthopedic technician, occupational therapist and social worker. This study involves conducting a case study to analyze the walking in the context of a transfemoral amputation. The support time on the ground, on the foot with which the subject walks with the prosthesis and the distance of the step of the prosthetic segment was evaluated.Kinovea is a free 2D motion analysis program that can be used to measure kinematic parameters and allows the user to control time parameters and evaluate angles and distances frame by frame. It allows the user to control time parameters and measure angles and distances frame by frame.
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Pre-operative assessment early postoperative treatment exercise programme early mobility assessment for prosthetic rehabilitation prosthetic services for the amputee gait re-education normal locomotion and prosthetic replacement the hemipelvectomy and hip disarticulation levels of amputation the above-knee level of amputation the through-knee levels of amputation the below-knee level of amputation the symes and partial foot levels of amputation advanced function bilateral amputees upper limb amputation nd congenital limb deficiency general advice to the amputee the problem of pain special cases.
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Phantom pain
Artificial limbs
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A 16-year-old girl presented for evaluation and management of a recurrent soft-tissue mass in her left hand after excision at another facility. She was given a diagnosis of clear cell sarcoma. She chose a limb salvage procedure over amputation. A triple central ray amputation of her index, middle, and ring fingers was performed. After 3 years, she has reasonable grasp function with her remaining fingers and has chosen not to use a prosthesis. Long-term follow-up is necessary for this tumor, as local recurrence and metastatic disease have been reported frequently.
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Partial traumatic hemipelvectomy (THP) is a catastrophic and life-threatening injury caused by high-energy impact. With advances in prehospital resuscitative techniques, more patients now survive this disastrous injury; however, the management of partial THP still lacks well-established therapeutic protocols. The purpose of this study was to present our experience in managing partial THP in a level-I trauma center.We retrospectively reviewed the medical records of 21 consecutive patients with partial THP. The key points of successful treatment are hemorrhage control, proper decision-making regarding amputation, treatment of associated injuries, and infection control. Data on patient demographics, injury characteristics, surgical management, and outcomes were recorded and analyzed.Eight female and 13 male patients with a mean age of 31.3 years met the diagnostic criteria. The mean follow-up was 51.9 months. Of 17 surviving patients, 7 underwent primary amputation; limbs were successfully preserved in 4; and 6 patients underwent secondary amputation because of infection, organ dysfunction, and limb necrosis. Two patients died during resuscitation, and 2 patients died after amputation. Phantom limb pain, infection, and skin flap necrosis were the major postoperative complications.THP requires cooperative multidisciplinary emergency diagnosis and treatment, early surgical intervention, and definitive treatment. Rapid resuscitation, adequate hemostasis, early amputation, and repeated debridement may improve survival.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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The Memorial Sloan-Kettering Cancer Center experience with major amputation for advanced malignant melanoma from 1965 to 1984 is reported. This is a retrospective review of 58 patients who underwent hemipelvectomy, disarticulation of the hip and above knee or forequarter amputation for advanced or recurrent malignant melanoma. Major amputation with curative intent was performed upon 43 patients. There were three deaths that occurred 30 days postoperatively (7 per cent). Intransit metastasis was one of the indications for amputation in 33 patients, and local control of disease was achieved in 30 of 43 patients. The median time to recurrence in those patients who did have a recurrence was 12 months (a range of 18 days to 16 years). Fifteen of 40 patients who survived the operation had no evidence of disease five years after undergoing a major amputation. Age, sex, primary site, stage of disease at diagnosis and amputation, disease-free interval and positive node status at any time during the course of the disease were not predictive of the outcome. Neurovascular involvement with melanoma and positive margins of resection predicted early failure. A palliative amputation for impending major vascular disruption or extensive, fungating disease was performed upon 15 patients. There was one death 30 days after the operation, and generally, hospitalization did not exceed 30 days. Median survival time was five months. All of the patients died of local or distant disease within 33 months of treatment. Local recurrence preceded death in nine of 15 patients.
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Objective To assess the resection,reconstruction,complication and treatment outcomes of the pelvic chondrosarcoma.Methods The data of 21 patients of pelvic chondrosarcoma were retrospectively reviewed.There were 12 females and 9 males with the median age of 46 years(range,16~65 years).According to Enneking pelvic classification system,2 patients were classified as type Ⅰ,5 as type Ⅰ and Ⅱ,6 as type Ⅱ,7 as type Ⅱ and Ⅲ,1 as type Ⅲ.The pathological details were:12 cases of well-differentiated chondrosarcoma,differentiated chondrosarcoma in 5 cases,2 cases of poorly differentiated chondrosarcoma,mesenchymal chondrosarcoma in 2 patients.Allograft was used in 2 patients after inactivation of tumor curettage.One patient underwent skeletal reconstruction of rod-screw system and allograft was used for pelvic repair in 1 patient after iliac local resection.One patient used autograft and internal fixation for reconstruction after pubis resection.Two patients underwent hemipelvectomy and 5 patients underwent internal hemipelvectomy.Acetabular reconstructions were performed in 9 cases.Results The average duration of follow-up was 39 months(range,7-100 months).Seventeen cases survived freely,2 survived with tumor,and 2 died.Local recurrence was observed in 5 of the 16 cases treated with widely excision,and it was also observed in 3 of the 5 cases treated with intralesional excision and marginal excision.The local recurrence rate and mortality rate in 21 patients with chondrosarcomas were 38.1% and 9.5%,respectively.The average ISOLS function score for the 19 patients was 19(range,7~25).The controllable complications occurred in 8 cases.Conclusions The best method for the pelvic chondrosarcoma treatment is wide excision.Prevention and active treatment of complications is the key to success of surgical treatment.
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Pelvic tumor
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Objective To review the long-term oncologic and functional outcomes of surgical treatment for pelvic chondrosarcoma at a single institution to further delineate surgical strategy of resection and function reconstruction.Methods All of 165 patients with pelvic chondrosarcoma that had been surgically treated between July 2000 and Dec 2013 were reviewed retrospectively.There were 102 male and 63 female patients who had a mean age of 43.5 (range,13 to 75) years.The resection type included Type T 16,type Ⅱ 18,type Ⅲ 11,type Ⅰ+Ⅱ 19,type Ⅱ+Ⅲ 63,type Ⅰ+Ⅳ 15,type Ⅰ+Ⅱ+Ⅲ 10 and type Ⅰ+Ⅱ+Ⅳ 13 cases.The pathology diagnosis was grade Ⅰ in 15,grade Ⅱ in 88,grade Ⅲ in 20,dedifferentiated in 28,mesenchymal in 12 and clear cell chondrosarcoma in 2 patients.Nine cases were secondary lesion following multiple exostoses.114 patients received no previous treatment while others were referred due to recurrent tumor.En bloc resection was achieved in 142 patients and intralesional resection in 23 cases.Twelve patients had a hemipelvectomy to achieve local tumor control,whereas 153 patients underwent a limb-salvage procedure.Spinal screw-rod system was used to reconstruct anterior pelvic ring after ilium resection.Modular hemipelvic endoprosthesis was utilized to reconstruct periacetabular defect after tumor resection while no reconstruction was performed after ischium and pubis resection.Results The median duration of follow-up was 54.1 (range,l0 to 159) months.147 (89.1％) patients were alive at the final follow-up,seven of which were alive with tumor.The estimated 5-year survival was 81.5％.Thirty-three patients (20％) had local recurrence,and twenty (12.1％) had lung metastasis.Recurrent case,sacroiliac joint involvement and intralesional resction were three risk factors for postoperative recurrence.Patients who received type Ⅱ+Ⅲ resection and reconstruction had a mean functional score of 23 according to MSTS 93.The mean MSTS 93 for patients with type Ⅰ+Ⅱ and type Ⅰ+Ⅱ+Ⅳ resection and reconstruction was 18.The wound complication rate was 15.8％.Two aseptic loosening and 2 pubic connection plate breakage were observed in hemipelvic endoprosthesis reconstruction.Conclusion Tumor grade correlates with overall or disease-free survival.For low-grade chondrosarcoma,adequate surgical margin can provide long-term local control while for high-grade cases,distant metastasis is the main case of treatment failure.Adequate surgical margin can be achieved in cases with acetabulum involved.However,aggressive surgical resection of pelvic chondrosarcoma still remains as a challenge for orthopaedic oncologists when the tumor invades the iliosacral joint,which necessitates careful preoperative plan and skilled surgical techniques.
Key words:
Pelvis; Chondrosarcoma; Treatment outcome
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Ischium
Pelvic tumor
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To investigate the clinical outcome of consecutive pelvic osteosarcoma treated with surgery and chemotherapy in a single institution, and to discuss the surgical strategy, resection and reconstruction.Twenty-one consecutive cases with pelvic osteosarcoma underwent surgical procedures between June 2000 and June 2009. There were 12 male and 9 female with a mean age of 32 years. According to Enneking and Dunham pelvic classification system, type Iwas 3 cases, type I+IV 3 cases, type I+II 4 cases, type II+III 4 cases, type I+II+III 1 case, type III 1 case, and type I+II+IV 5 cases. Among the 21 cases, 19 were diagnosed as classical osteosarcoma and 2 were diagnosed as low-grade pathologically. All the tumors were stage IIB. All the patients received en-bloc resection with 13 wide resection and 8 marginal resection. Thirteen patients underwent modular hemi-pelvic endoprosthesis reconstruction, and 5 patients underwent rod-screw system reconstruction combined with autograft. Two patients received hemipelvectomy and one type III patients had resection without reconstruction. The mean follow-up period was 30.3 months (range, 6.0-87.0).Thirteen patients out of 21 survived after treatment. The overall survival rate was 61.9%, and 23.8% patients were alive without disease. The estimated 5-year survival rate was 44.2% based on Kaplan-Meier curve. The local recurrence rate was 28.6%, among which 4 cases were type II resection, 1 was type I resection, 1 was type I+IV resection.No local relapse was found on the hemipelvectomy and type III resection cases. The local recurrence rate after wide resection was 23.1%, and 37.5% for marginal resection.Nine patients had lung metastases and one patient was found bone and lymph node metastases. The MSTS 93 function score was 20.6 ± 5.4 for 13 patients, and 22.5 ± 2.1 for rod-screw reconstruction cases. The function score was 17.7 ± 5.5 for hemi-pelvic prosthetic reconstruction.Limb salvage procedures could be performed on most pelvic osteosarcoma cases, and satisfying function outcome could be achieved with proper reconstruction, however, the overall survival is still lower compared with those in extremities.
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Pelvic tumor
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