Abstract
Background
Surgical treatment of pelvic tumors with or without acetabular involvement is challenging. Primary goals of surgery include local control and maintenance of good quality of life, but the procedures are marked by significant perioperative morbidity and complications.
Questions/purposes
We wished to (1) evaluate the frequency of infection after limb salvage surgical resection for bone tumors in the pelvis; (2) determine whether infection after these resections is associated with particular risk factors, including pelvic reconstruction, radiotherapy or chemotherapy, type of resection, and age; and (3) analyze treatment of these infections, particularly with respect to the need of additional surgery or hemipelvectomy.
Methods
From 1975 to 2010, 270 patients with pelvic bone tumors (149 with chondrosarcoma, 40 with Ewing’s sarcoma, 27 with osteosarcoma, 18 with other primary malignant tumors, 11 with metastatic tumors, and 25 with primary benign tumors) were treated by surgical resection. Minimum followup was 1.1 years (mean, 8 years; range, 1–33 years). The resection involved the periacetabular area in 166 patients. In 137 patients reconstruction was performed; in 133 there was no reconstruction. Chart review ascertained the frequency of deep infections, how they were treated, and the frequency of resection arthroplasty or hemipelvectomies that occurred thereafter.
Results
A total of 55 patients (20%) had a deep infection develop at a mean followup of 8 months. There were 20 infections in 133 patients without reconstruction (15%) and 35 infections in 137 patients with reconstruction (26 %). Survivorship rates of the index procedures using infection as the end point were 87%, 83%, and 80% at 1 month, 1 year, and 5 years, respectively. Infection was more common in patients who underwent pelvic reconstruction after resection (univariate analysis, p = 0.0326; multivariate analysis, p = 0.0418; odds ratio, 1.7718; 95% CI, 1.0243–3.0650); no other risk factors we evaluated were associated with an increased likelihood of infection. Despite surgical débridements and antibiotics, 16 patients (46%) had the implant removed and five (9%) underwent external hemipelvectomy (four owing to infection and one as a result of persistent infection and local recurrence).
Conclusions
Infection is a common complication of pelvic resection for bone tumors. Reconstruction after resection is associated with an increased risk of infection compared with resection alone, without significant difference in percentage between allograft and metallic prosthesis. When infection occurs, it requires removal of the implant in nearly half of the patients who have this complication develop, and external hemipelvectomy sometimes is needed to eradicate the infection.
Level of Evidence
Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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References
Aboulafia AJ, Buch R, Mathews J, Li W, Malawer MM. Reconstruction using the saddle prosthesis following excision of primary and metastatic periacetabular tumors. Clin Orthop Relat Res. 1995;314:203–213.
Aboulafia AJ, Malawer MM. Surgical management of pelvic and extremity osteosarcoma. Cancer. 1993;71(10 suppl):3358–3366.
Abudu A, Grimer RJ, Cannon SR, Carter SR, Sneath RS. Reconstruction of the hemipelvis after the excision of malignant tumours: complications and functional outcome of prostheses. J Bone Joint Surg Br. 1997;79:773–779.
Aljassir F, Beadel GP, Turcotte RE, Griffin AM, Bell RS, Wunder JS, Isler MH. Outcome after pelvic sarcoma resection reconstructed with saddle prosthesis. Clin Orthop Relat Res. 2005;438:36–41.
Angelini A, Guerra G, Mavrogenis AF, Pala E, Picci P, Ruggieri P. Clinical outcome of central conventional chondrosarcoma. J Surg Oncol. 2012;106:929–937.
Beadel GP, McLaughlin CE, Wunder JS, Griffin AM, Ferguson PC, Bell RS. Outcome in two groups of patients with allograft-prosthetic reconstruction of pelvic tumor defects. Clin Orthop Relat Res. 2005;438:30–35.
Bell RS, Davis AM, Wunder JS, Buconjic T, McGoveran B, Gross AE. Allograft reconstruction of the acetabulum after resection of stage-IIB sarcoma: intermediate-term results. J Bone Joint Surg Am. 1997;79:1663–1674.
Biau D, Thévenin F, Dumaine V, Babinet A, Tomeno B, Anract P. Ipsilateral femoral autograft reconstruction after resection of a pelvic tumor. J Bone Joint Surg Am. 2009;91:142–151.
Campanacci M, Capanna R. Pelvic resections: the Rizzoli Institute experience. Orthop Clin North Am. 1991;22:65–86.
Capanna R, van Horn JR, Guernelli N, Briccoli A, Ruggieri P, Biagini R, Bettelli G, Campanacci M. Complications of pelvic resections. Arch Orthop Trauma Surg. 1987;106:71–77.
Carter SR, Eastwood DM, Grimer RJ, Sneath RS. Hindquarter amputation for tumours of the musculoskeletal system. J Bone Joint Surg Br. 1990;72:490–493.
Cottias P, Jeanrot C, Vinh TS, Tomeno B, Anract P. Complications and functional evaluation of 17 saddle prostheses for resection of periacetabular tumors. J Surg Oncol. 2001;78:90–100.
Delloye C, Banse X, Brichard B, Docquier PL, Cornu O. Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor. J Bone Joint Surg Am. 2007;89:579–587.
Donati D, Di Bella C, Frisoni T, Cevolani L, DeGroot H. Alloprosthetic composite is a suitable reconstruction after periacetabular tumor resection. Clin Orthop Relat Res. 2011;469:1450–1458.
Donati D, El Ghoneimy A, Bertoni F, Di Bella C, Mercuri M. Surgical treatment and outcome of conventional pelvic chondrosarcoma. J Bone Joint Surg Br. 2005;87:1527–1530.
Enneking WF. Pelvis. In: Enneking WF, ed. Musculoskeletal Tumor Surgery. New York, NY: Churchill-Livingstone; 1983:483–490.
Enneking WF, Dunham WK. Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg Am. 1978;60:731–746.
Gebert C, Wessling M, Hoffmann C, Roedl R, Winkelmann W, Gosheger G, Hardes J. Hip transposition as a limb salvage procedure following the resection of periacetabular tumors. J Surg Oncol. 2011;103:269–275.
Guo W, Li D, Tang X, Ji T. Surgical treatment of pelvic chondrosarcoma involving periacetabulum. J Surg Oncol. 2010;101:160–165.
Guo W, Li D, Tang X, Yang Y, Ji T. Reconstruction with modular hemipelvic prostheses for periacetabular tumor. Clin Orthop Relat Res. 2007;461:180–188.
Guo W, Sun X, Ji T, Tang X. Outcome of surgical treatment of pelvic osteosarcoma. J Surg Oncol. 2012;106:406–410.
Guo Z, Li J, Pei GX, Li XD, Wang Z. Pelvic reconstruction with a combined hemipelvic prostheses after resection of primary malignant tumor. Surg Oncol. 2010;19:95–105.
Ham SJ, Schraffordt Koops H, Veth RP, van Horn JR, Eisma WH, Hoekstra HJ. External and internal hemipelvectomy for sarcomas of the pelvic girdle: consequences of limb-salvage treatment. Eur J Surg Oncol. 1997;23:540–546.
Han I, Lee YM, Cho HS, Oh JH, Lee SH, Kim HS. Outcome after surgical treatment of pelvic sarcomas. Clin Orthop Surg. 2010;2:160–166.
Harrington KD. The use of hemipelvic allografts or autoclaved grafts for reconstruction after wide resections of malignant tumors of the pelvis. J Bone Joint Surg Am. 1992;74:331–341.
Hillmann A, Hoffmann C, Gosheger G, Rodl R, Winkelmann W, Ozaki T. Tumors of the pelvis: complications after reconstruction. Arch Orthop Trauma Surg. 2003;123:340–344.
Jaiswal PK, Aston WJ, Grimer RJ, Abudu A, Carter S, Blunn G, Briggs TW, Cannon S. Peri-acetabular resection and endoprosthetic reconstruction for tumours of the acetabulum. J Bone Joint Surg Br. 2008;90:1222–1227.
Kaplan E, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457–481.
Laffosse JM, Pourcel A, Reina N, Tricoire JL, Bonnevialle P, Chiron P, Puget J. Primary tumor of the periacetabular region: resection and reconstruction using a segmental ipsilateral femur autograft. Orthop Traumatol Surg Res. 2012;98:309–318.
Langlais F, Lambotte JC, Thomazeau H. Long-term results of hemipelvis reconstruction with allografts. Clin Orthop Relat Res. 2001;388:178–186.
Mankin HJ, Doppelt S, Tomford W. Clinical experience with allograft implantation: the first ten years. Clin Orthop Relat Res. 1983;174:69–86.
Masterson EL, Davis AM, Wunder JS, Bell RS. Hindquarter amputation for pelvic tumors: the importance of patient selection. Clin Orthop Relat Res. 1998;350:187–194.
Mavrogenis AF, Soultanis K, Patapis P, Guerra G, Fabbri N, Ruggieri P, Papagelopoulos PJ. Pelvic resections. Orthopedics. 2012;35:e232–243.
Ozaki T, Hillmann A, Bettin D, Wuisman P, Winkelmann W. High complication rates with pelvic allografts: experience of 22 sarcoma resections. Acta Orthop Scand. 1996;67:333–338.
Ozaki T, Hillmann A, Lindner N, Blasius S, Winkelmann W. Chondrosarcoma of the pelvis. Clin Orthop Relat Res. 1997;337:226–239.
Ozaki T, Hoffmann C, Hillmann A, Gosheger G, Lindner N, Winkelmann W. Implantation of hemipelvic prosthesis after resection of sarcoma. Clin Orthop Relat Res. 2002;396:197–205.
Petrie A. Statistics in orthopaedic papers. J Bone Joint Surg Br. 2006;88:1121–1136.
Puri A, Gulia A, Jambhekar NA, Laskar S. Results of surgical resection in pelvic Ewing’s sarcoma. J Surg Oncol. 2012;106:417–422.
Rodl RW, Hoffmann C, Gosheger G, Leidinger B, Jurgens H, Winkelmann W. Ewing’s sarcoma of the pelvis: combined surgery and radiotherapy treatment. J Surg Oncol. 2003;83:154–160.
Satcher RL Jr, O’Donnell RJ, Johnston JO. Reconstruction of the pelvis after resection of tumors about the acetabulum. Clin Orthop Relat Res. 2003;409:209–217.
Schwameis E, Dominkus M, Krepler P, Dorotka R, Lang S, Windhager R, Kotz R. Reconstruction of the pelvis after tumor resection in children and adolescents. Clin Orthop Relat Res. 2002;402:220–235.
Senchenkov A, Moran SL, Petty PM, Knoetgen J 3rd, Clay RP, Bite U, Barnes SA, Sim FH. Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases. Ann Surg Oncol. 2008;15:355–363.
Sheth DS, Yasko AW, Johnson ME, Ayala AG, Murray JA, Romsdahl MM. Chondrosarcoma of the pelvis: prognostic factors for 67 patients treated with definitive surgery. Cancer. 1996;78:745–750.
Shin K-H, Rougraff BT, Simon MA. Oncologic outcomes of primary bone sarcomas of the pelvis. Clin Orthop Relat Res. 1994;304:207–217.
Windhager R, Karner J, Kutschera HP, Polterauer P, Salzer-Kuntschik M, Kotz R. Limb salvage in periacetabular sarcomas: review of 21 consecutive cases. Clin Orthop Relat Res. 1996;331:265–276.
Wirbel RJ, Schulte M, Maier B, Mutschler WE. Megaprosthetic replacement of the pelvis: function in 17 cases. Acta Orthop Scand. 1999;70:348–352.
Wirbel RJ, Schulte M, Mutschler WE. Surgical treatment of pelvic sarcomas: oncologic and functional outcome. Clin Orthop Relat Res. 2001;390:190–205.
Yoshida Y, Osaka S, Mankin HJ. Hemipelvic allograft reconstruction after periacetabular bone tumor resection. J Orthop Sci. 2000;5:198–204.
Yuen A, Ek ET, Choong PF. Research: is resection of tumours involving pelvic ring justified? A review of 49 consecutive cases. Int Semin Surg Oncol. 2005;2:9.
Zeifang F, Buchner M, Zahlten-Hinguranage A, Bernd L, Sabo D. Complications following operative treatment of primary malignant bone tumours in the pelvis. Eur J Surg Oncol. 2004;30:893–899.
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Angelini, A., Drago, G., Trovarelli, G. et al. Infection After Surgical Resection for Pelvic Bone Tumors: An Analysis of 270 Patients From One Institution. Clin Orthop Relat Res 472, 349–359 (2014). https://doi.org/10.1007/s11999-013-3250-x
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DOI: https://doi.org/10.1007/s11999-013-3250-x