1. COMPLICATIONS – AND THEIR MANAGEMENT – IN PELVIC MUSCULOSKELETAL TUMOR SURGERY (EXPECT THE UNEXPECTED) Harzem ÖZGER, Buğra ALPAN, Mustafa SUNGUR, Levent ERALP Istanbul University, Istanbul Faculty of Medicine, Department of Orthoapedics and Traumatology

2. Pelvic musculoskeletal tumor surgery complex anatomy proximity of tumoral masses to vital neurovascular structures gastrointestinal system urogenital systems   morbidity & mortality of complications

3. In the literature, aggressive surgical treatment is justified for malignant tumors of the pelvis despite morbidity and mortality. J Bone Joint Surg Am. 2001 Nov;83-A(11):1630-42. Chondrosarcoma of the pelvis. A review of sixty-four cases. Pring ME, Weber KL, Unni KK, Sim FH. Clin Orthop Relat Res. 2009 Feb;467(2):510-8. Epub 2008 Oct 15. Osteosarcoma of the pelvis: outcome analysis of surgical treatment. Fuchs B, Hoekzema N, Larson DR, Inwards CY, Sim FH. Cancer. 1999 Feb 15;85(4):869-77. Pelvic Ewing sarcoma: a retrospective analysis of 241 cases. Hoffmann C, Ahrens S, Dunst J, Hillmann A, Winkelmann W, Craft A, Göbel U, Rübe C, Voute PA, Harms D, Jürgens H

4. Reports on complications are very limited Infection, LLD, hematoma, skin problems were listed as complications in one patient series. Using autografts instead of allografts were advised because of lower incidence of complications Arch Orthop Trauma Surg. 2003 Sep;123(7):340-4. Epub 2003 Jun 28. Tumors of the pelvis: complications after reconstruction Hillman A, Hoffmann C, Gosheger G, Rödl R, Winkelmann W, Ozaki T

5. Evaluation of complications “problem-obstacle-sequela” approach originally devised for limb lengthening complications adapted to complications of pelvic tumor surgery Problem : conservative management Obstacle : requiring surgical intervention Sequela : permanent disability

6. Patients and Methods 1988-2009 89 patients mean age: 33.7 (2-74) primary malignant & local aggressive lesions of pelvis 4 died periop due to extensive blood loss 7 lost to follow-up 8 excluded due to insufficient data. Mean follow-up: 29.4 months (1 – 216) for remaining pts.

9. What do we expect? Predictable: Complications caused by planned sacrification of certain anatomical parts (sacral roots, sciatic nerve, femoral nerve, hip joint) and caused by extensive surgical exposure and dead space wound problems (24) gait difficulty (21) urinary incontinence (9) leg length discrepancy (9) deep infection (8) paralysis of lower extremities (7) anal incontinence (5)

10. What is not expected? Unpredictable: Theoretically recognized complications not predicted for that particular case ( iatrogenic injury, failure to complete full resection / recon-struction due to anesthesia-related complications, late / secondary complications ) intraoperative hemorrhagic shock (8) iatrogenic injuries of urinary system (4) and rectum (1) inadequate lumbopelvic stabilization (3) neuropathic pain (3) hydronephrosis and urinary leakage (1) meningitis secondary to CSF leakage (1) abdominal hernia (1) mechanical ileus (intest. adhesions) (1)

11. Results Pts included: 70 Pts with complication: 49 (70.0 %) Total no. of complications: 106 Complications / pt : 1.5 Predictable complications: 83 (78.3 %) Unpredictable complications: 23 (21.7%) Surgical interventions for compl: 25 (23.6%) Surgical intervention for compl/pt: 0.36

12. Complication Management wound problems deep infections (CNS infection) occasionally Problem -broad-spectrum IV antibiotics - VAC Obstacle - local surgical debridement - local flaps, STSG - colostomy to reduce wound contamination, for rectal fistula - (cranial drainage cath. for meningitis) mostly

13. - 67 y/o M - pleomorphic sarcoma of right iliac wing. - WR + Sacroacetabular fixation - wound problem + deep infection postop third week - VAC and STSG

14. - 69 y/old M - recur. sacral chordoma. -extensive wound problems - Myofasciocutaneous flaps

15. neurologic deficit neuropathic pain mostly occasionally Sequela (permanent deficit) -Bracing & physiotherapy for lower extremity -Intermittent urinary catheterization for incontinence Obstacle (muscle transfer ? ) Problem (transient deficit) - Oral gabapentin for neuropathic pain - Bracing & Physiotherapy - Urinary catheterization Complication Management

16. -20 y/o F -GCT of sacrum -Neurogenic bladder at postop 4 wks. -Urinary catheterization

17. limb length discrepancy limping mostly Sequela - Shoe elevation - Orthoses - Physiotherapy for hip ROM and strengthening of gluteal muscles Obstacle - Limb lengthening with EF Complication Management

18. - 54 y/old M with CS of acetabulum. - Gait difficulty accepted as sequela - Managed with two crutches, bracing and physiotherapy.

19. - 24 y/o F - chondroblastoma of acetabulum - at postop 9 yrs - LLD was an obstacle, lengthening was performed. - Hip abductor weakness sequela Postop + 1 y

20. - 19 y/o F - RT for pelvic EWS at 6 y - Pelvic asymmetry causing LLD SEQUELA or OBSTACLE ??

21. 1 year later lengthening and consolidation complete

22. Ureter / bladder / urethra injuries Complication Management Problem - Urethral urinary catheterization for urethral injury Obstacle - Intraoperative repair of ureter, bladder, prostate - Cystostomy for urethral injuries - Nephrostomy for hydronephrosis due to ureteral injury

23. Often multiple problems need to be addressed simultaneously Complication Management

24. - 18 y/o M - OS of sacrum + L5 - Extensive wound problem, deep infection, ureteral injury and hydronephrosis - Intraoperative abundant bleeding compromised lumbopelvic fixation - Bilateral nephrostomy - Repeat debridements - VAC - Sciatic nerve sacrification

25. -16 y/o F - osteosarcoma of right hemipelvis - Internal hemipelvectomy + hip transposition - early wound problem was treated - sciatic nerve sacrification combined with gluteal weakness caused dropfoot and gait difficulty. Accepted as sequela. - Walker + AFO

26. Preventive measures: local flaps and silicon implants as spacers (10) colostomy (9) preoperative embolisation (7) pig-tail ureteral catheterisation (3). Complication Management

27. Pre-embolization Post-embolization - 30 y/o F - Sacral chordoma

30. - postop 8 months - permanent colostomy

31. - 17 y/o M with OS of right hemipelvis - double J-catheterization preop to avoid ureter injury – successful - neuropathic pain due to femoral head pressing on lumbosacral plexus – oral gabapentin

32. Conclusion Multi-disciplinary approach pre-, intra- and postoperatively to reduce predictable and unpredictable complications. Pelvic tumor surgery has high morbidity and mortality. However, if not treated, malignant and local aggressive pelvic tumors cause sequela and eventually death. Therefore it is favorable for the surgeon to manage complications of surgery at problem or obstacle level.

33. Thank you for your attention…