1. Functional and oncologic outcome after combined allograft and total hip arthroplasty reconstruction of large pelvic bone defects following tumour resection. Gordon Beadel, MB ChB, FRACS Anthony Griffin, BSc Christian Ogilvie, MD Jay Wunder, MD, FRCSC Robert Bell, MD, FRCSC Peter Ferguson, MD, FRCSC Mt Sinai Hospital Toronto, Ontario, Canada

2. CTOS, Montreal, November 2004. Introduction Resection of large pelvic bone tumours often results in –segmental pelvic defect –pelvic discontinuity –loss of acetabulum

3. CTOS, Montreal, November 2004. Several Options for Reconstruction -allograft bone hemipelvic allograft smaller structural allograft –vascularised bone graft –reinsertion irradiated/autoclaved resection specimen –hemipelvic prosthetic replacement –saddle prosthesis –Arthrodesis

4. CTOS, Montreal, November 2004. Mount Sinai Hospital Approach it has been the practice of our unit to use allograft reconstruction combined with THA we have identified two distinct groups based on –technical difficulties of the procedure –complications –long term outcome

5. CTOS, Montreal, November 2004. Two Groups Hemipelvic graft Peri-acetabular graft

6. CTOS, Montreal, November 2004. Purpose & Method  Review functional and oncologic outcomes of these two groups local ethics committee approval obtained retrospective review of our prospectively collected database undertaken –database ongoing since 1989 –all patients who had undergone combined pelvic allograft and THA reconstruction for bone tumour were identified and included

7. CTOS, Montreal, November 2004. Anatomic tumour extent was described by Enneking & Dunham classification: –zone I:supra-acetabular ilium –zone II:peri-acetabular –zone III:ischium, inferior and superior pubic rami

8. CTOS, Montreal, November 2004. Two patient groups were –Group 1 Hemipelvic resection Zones I + II or Zones I + II + III –Group 2 periacetabular resection Zone II Group 1 Group 2

9. CTOS, Montreal, November 2004. Group 1 –19 patients 12 type I + II resections 7 type I + II + III resections included 11 cases requiring partial sacral resection 5 patients required nerve resection –sciatic nerve - 1 case –nerve roots - 4 cases

10. CTOS, Montreal, November 2004. Group 1 reconstruction –19 cases irradiated hemipelvic allograft and THA –all cemented acetabular implants –proximal femoral replacement implant in 1 case –mesh capsular reconstruction in 12 cases

11. CTOS, Montreal, November 2004. Group 2 –5 patients –type II resection all were proximal femoral primary tumours requiring extra-articular peri-acetabular resection no nerve resections required

12. CTOS, Montreal, November 2004. Results minimum follow up 15 months –group 1: 17-167 months –group 2: 15-154 months average age –group 1: 41 years (16-64) –group 2: 42 years (31-50)

13. CTOS, Montreal, November 2004. Histology

14. CTOS, Montreal, November 2004.

15. average surgical times group 1594 mins (450-728) group 2596 mins (510-704) returns to the OR –group 112 patients (63%) average 3.2 times (range 1 to 6) –group 21 patient (20%) 2 times

16. Group 1 hemipelvic allograft functional outcomes

17. CTOS, Montreal, November 2004. –7 patients (37%) allograft remained intact without infection 3 patients –revision THAs »for allograft fractures and THA loosening average scores for these 7 patients –TESS 64 –MSTS87 17/35 –MSTS9345% –average time to score52 months (3 - 120)

18. CTOS, Montreal, November 2004. –9 patients had deep infection (47%) –1 patient 2° to unrelated peritoneal sepsis 3 patients maintained a functional implant with long term antibiotic suppression –TESS30 (22.2-37.5) –MSTS8715/35(12-17/35) –MSTS9341%(33-50) –average time to scores30 months (6-60) 1 patient –allograft removal 4 patients –hindquarter amputation 1 patient –allograft fragmentation in situ

19. Group 2 periacetabular reconstruction functional outcomes

20. CTOS, Montreal, November 2004. –3 patients no complications –2 patients complications –1case - 1 dislocation –1 case - 3 dislocations + ? ant. acetabular wall allograft #

21. CTOS, Montreal, November 2004. –functional scores TESS78 MSTS8717/35 MSTS9364% –time to scores average55 months range12 - 120 months

22. The good

23. CTOS, Montreal, November 2004. 47 yrs female 15 years post type I + II resection for chondrosarcoma Revision THA for acetabular loosening at 8 years doing well walks with single cane

24. CTOS, Montreal, November 2004. 53 yrs, male 3 years post extra articular resection prox femoral chondrosarcoma doing well single cane

25. The not so good

26. CTOS, Montreal, November 2004. 65 yrs, male 9 yrs post type I + II + III resection for chondrosarcoma chronic infection managed with suppressive antibiotics large inguinal hernia uses 2 crutches

27. The bad

28. CTOS, Montreal, November 2004. 60 yrs, male 5 yrs post type Is + II + III for chondrosarcoma wound necrosis, infection, antibiotic suppression, allograft fracture 2 crutches / wheelchair

29. CTOS, Montreal, November 2004. Conclusions Composite hemipelvic allograft and THA reconstruction of massive pelvic defects –when successful (1/3 patients) provides a reasonable level of function and a satisfactory outcome –but is associated with high rates of major complications infection

30. CTOS, Montreal, November 2004. In comparison smaller structural allograft and THA composite reconstructions for type II acetabular resections –more predictable and have a better outcome –resulting in a good level of function –lower complication rate