Hemipelvectomy- Only a Salvage Therapy?

Orthopedic Reviews 2011; volume 3:e4

Hemipelvectomy- only a salvage to resect. Therefore, pelvic tumors present a great challenge for orthopedic surgeons. Correspondence: Priv.-Doz. Dr. med Christian therapy? Basically, hemipelvectomy is divided into Wedemeyer, Department of Orthopaedic Surgery, external hemipelvectomy (amputation) and University of Duisburg-Essen, Hufelandstraße Christian Wedemeyer,1 internal hemipelvectomy with preservation of 55, 45147 Essen, Germany. Max Daniel Kauther2 the lower extremity. For many years external Tel. 49.201.723.3181 - Fax: +49.201.4089.2722. E-mail: [email protected] 1Department of Orthopedic Surgery, hemipelvectomy was the standard method of University Duisburg-Essen, Essen; treatment for locally aggressive and malignant Key words: hemipelvectomy, bone tumors, recon- 2Department of Trauma Surgery, bone tumors in the pelvis. Today, internal struction, oncological outcome. University Duisburg-Essen, Essen, hemipelvectomy presents an alternative in the 7,8 Acknowledgement: the authors would like to Germany struggle against pelvic tumors. Since an adequate and tumor free resection margin is of thank Kaye Schreyer, Dr. Anja Wedemeyer and Dr. great importance for the long-term oncological Cordula Kauther for editorial assistance with the manuscript. outcome, hemipelvectomy remains as a curative approach.9-11 It is evident that not only sur- Abstract Conflict of interest: the authors report no con- gical technique but relevant development on flicts of interest. non-orthopaedic fields such as early diagnosis After the first hemipelvectomy in 1891 sig- and follow-ups by imaging, new chemotherapy Received for publication: 15 February 2011. nificant advances have been made in the fields Revision received: 3 March 2011. and/or radiation regimes, and innovative Accepted for publication: 4 March 2011. of preoperative diagnosis, surgical technique implants or bioengineering have lead to signif- and adjuvant treatment in patients with pelvic icant improvement in the management and This work is licensed under a Creative Commons tumors. The challenging surgical removal of success of hemipelvectomy. Modern imaging Attribution 3.0 License (by-nc 3.0). these rare malignant bone or soft tissue techniques allow early and accurate preopera- tumors accompanied by interdisciplinary ther- tive staging.12 Inoperable neoplasms become ©Copyright C. Wedemeyer and M.D.Kauther, 2011 apy is mostly the only chance of cure, but bares operable by neoadjuvant chemotherapy and Licensee PAGEPress, Italy Orthopedic Reviews 2011; 3:e4 the risk of intensive bleeding and infection. preoperative irradiation aiming to reduce the doi:10.4081/or.2011.e4 The reconstruction after hemipelvectomy is of tumor mass and increasing the chance to pre- importance for the later outcome and quality of serve the lower extremity.13 With adequate life for the patient. Here, plastic surgery with management internal hemipelvectomies do microvascular free flaps or local rotational not implement higher recurrence rates com- review presents the literature on the outcome flaps improved the reconstruction and reduced pared to amputations by external hemipelvec- after hemipelvectomy in dependency of infection rates. Average local recurrence rates tomy14 and, in contrast, lead to better function- defined reconstruction techniques during the of 14% demonstrate good surgical results, but al results in many cases.15 For reconstruction last thirty years. 5 year survival rates of only 50% are described of the hip and the hemipelvis after tumor for some tumor entities, showing the impor- resections various techniques have been Entities tance of a multimodal collaboration. On a basis developed to obtain a functional and cosmeti- Bone tumors can develop in all types of bone of a selective literature review the history, cally acceptable outcome, especially to prevent tissue and associated bone marrow cells. A indications, treatment options and outcome of from highshortening of the limb even after a tumor that originates in bone is called primary hemipelvectomies are presented. wide resection.16 bone cancer. Primary bone tumors only First, there is the possibility of solely resect- account for 1% of all solid tumors, and mostly ing the bone. In this procedure, fresh frozen affect patients under 20 years and between 40 allografts17 or autografts are frequently used - 50 years.26 The tumors most commonly occur- Introduction for bony reconstruction. Here, also re-implan- ring in the pelvis are chondrosarcoma, Ewing tion of devitalized autogenous bone16 was sarcoma, plasmocytoma and osteosarcoma. In The first hemipelvectomy was performed by reported. There are also options for recon- rare cases, histiocytoma, lymphoma, rhab- Billroth in 1891. The patient survived only a few struction by means of allograft or autograft domyosarcoma and fibrosarcoma are located hours. In 1893, Jabulay operated on a patient interposition in combination with a total in the pelvis.27 Osteosarcomas are considered who died immediately after the procedure. The hip15,18,19 or even pelvis prosthesis,20 by transpo- to be the most common primary malignant first successful hemipelvectomy in terms of sur- sition of the hip joint or by arthrodesis21,22 and bone tumors with 150 cases per year in vival was performed by Girard in 1895. In 1902, hindfoot rotationplasty. Furthermore, there Germany.28 While this tumor type is mainly there were reports on 13 hemipelvectomies has been an attempt to reconstruct the pelvis located in the metaphysis of long bones, the with a mortality rate of 60%.1,2 The most com- with polymethylmethacrylate (PMMA) com- incidence rate in the pelvis is only 6.4-8% of all mon indications for hemipelvectomy are bined with screws or nails.23 However, the lat- osteosarcomas and thus comparatively rare.29 malignant or locally aggressive/ destructive ter techniques only appropriate for palliative Chondrosarcomas are the second most com- bone and soft tissue tumors of the pelvis and situations or temporary reconstruction. There mon malignant bone tumors.30 They are usual- the adjacent muscles, especially osteosarcoma, is no standard procedure and little information ly located close to the trunk and the pelvic chondrosarcoma and Ewing's sarcoma. In is available about the results although many skeleton. This differs from the osteosarcoma, some rare cases hemipelvectomy is also neces- different options exist for reconstruction after which is found in the pelvis only in exception- sary because of trauma3 or osteomyelitis.4 The internal hemipelvectomy. It is also much al cases.30,31 Chondrosarcomas have to be treat- overall prognosis for patients with malignant debate about which approach is appropriate for ed primarily by surgical therapy, because bone tumors is poor.5,6 Due to the location and each single patient.12,24 The decision regarding chemotherapy and radiation therapy are most- extension of these lesions but also to the com- surgical strategy takes into account the age of ly not effective.8 Here, a wide surgical resec- plex anatomy and the aim to achieve a good the patient,15 the required extent of resection tion margin is crucial for successful treatment. functional outcome, these tumors are difficult and the experience of the surgeons.12,25 This A further 10% of malignant bone tumors are

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Ewing sarcomas with an annual incidence of removal is often quiet technical difficult and 0.6/million in the population.30 In children and embare a high complication risk, these opera- young adults they are the second most com- tions should not be performed as a purely pal- mon primary bone tumors.30 Recent studies liative procedure.37 Indications for palliative suggested that Ewing sarcomas probably origi- radical amputation are the involvement of nate from undifferentiated mesenchymal cells nerve structures in the pelvis causing uncon- of the bone marrow and are mainly located in trollable pain and failed local control of the metaphysis and diaphysis and in the metastatic disease. However, such cases are pelvis. Other authors believed that Ewing sar- rare. Severe trauma38 or osteomyelitis4 of the comas belong to the primitive neuroectoder- pelvis may also indicate hemipelvectomy in mal tumors, derived from the neural crest and defined cases. Amputation is recommended if are characterized by ews/ets translocation. the tumor has infiltrated the sciatic nerve and However, the exact origin of Ewing sarcoma therefore relevant function of the lower family is unknown.32,33 Seven percent of all extremity is not to be expected.39 bone tumors are primary non-Hodgkin's lym- Figure 1. Subtypes of hemipelvic resection phoma.34 Like the Ewing sarcoma, this rare Surgical, anatomical and patient methods, Eneking and Dunham 1978, tumor affects the metaphysis of long bones related aspects of hemipelvectomy Figure redrawn.44 Type I: resection includes and the pelvis.34 only the ilium. Type IA: resection of the Detailed descriptions of surgical approaches ilium and the gluteal muscles. Type I/S: are found in literature.40 Prior to biopsy the Resection of the ilium with a portion of the Indications for hemipelvectomy surgeon needs to have detailed information of sacrum. Type II: Resection of the periac- Tumors of the pelvis are often recognized at tumor’s extent and, in case of malignancy, of etabular region. Type IIA: Resection of the a late stage because they can extend without the tumor resection to be performed later in periacetabular region including the hip inducing local symptoms. At the time of diag- joint. Type III: Resection of parts or the order to avoid contamination of tumor-free tis- complete ischium and pubis. nosis they often have a high tumor mass and sue. Resection should be performed according are located close to vessels or nerves. The to the usual standard oncological-surgical greatest problem involved in resection is the methods.41,43 There is general consent that the need for oncological radicalism on the one resection margin should be 3-5 cm but not gery result in a better functional outcome com- hand, while aiming to obtain a good functional smaller. Tumor resections are classified into pared with conditions after amputation.49 outcome on the other. Limb-saving surgery four categories:43 i) Intralesional tumor should only be conducted if the tumor can be Pring described a good functional result of 77% removal: The tumor mass is resected macro- according to the Musculosceletal Tumor completely removed or if an external scopically with contaminated margins in histo- hemipelvectomy does not allow more radical Society Score (MSTS) after chondrosarcoma logical evaluation. For primary malignant 50 oncological results.35 It is essential for the sur- resection and limb-saving surgery. tumors this resection must be regarded as 51 geon to have detailed knowledge of the Karaharju emphasized the psychological inacceptable; ii) marginal resection is a resec- anatomical location of the tumor including the advantage for the patient after internal tion in the reactive zone of the tumor. involvement of surrounding anatomical struc- hemipelvectomy. Furthermore, phantom pain Microscopically reactive tissue or micro-satel- tures in order to plan a specific surgical and and extensive intraoperative blood loss are typ- lites can be detected; iii) an intra-compart- 52,53 individually procedure.17 To determine the true ical complications of amputations. The mental resection margin is a resection outside extent of the tumor, it is therefore essential postoperative course after external hemipelve - the reactive zone in normal tissue. Therefore, that comprehensive preoperative radiographic ctomy may be complicated by wound healing it is called wide resection. Skip lesions are staging including bone x-rays, chest and disorders, bladder, sexual and bowel dysfunc- abdominal computer-tomography (CT), mag- occasionally detected; iv) a radical surgical tion. netic resonance imaging (MRI) for soft tissue (extra-compartmental resection) procedure is imaging and an angiography are carried out. In a complete removal of the affected compart- Functional outcome in pelvic addition, bone scans may detect additional ments and the resection margin is in healthy reconstructions 41 skip lesions or unknown metastasis. tissue. Enneking and Dunham proposed a Once the decision has been made for limb- Regarding the extent of the tumor, the sacro- classification scheme for description of vari- saving surgery, the choice of the appropriate 41 iliac joint, the symphysis, the peritoneum and ous subtypes of pelvic resections (Figure 1). pelvic reconstruction needs to be made: if the the bladder are critical areas. Although ade- When reconstructing bone defects, it is tumor is in the area of the pubis, the ischium quate oncological resections in these areas are always important to ensure sufficient muscu- or the peripheral iliac wing without interrup- surgical demanding, amputation is not always lar coverage.17,18,35,45-47 This coverage lowers the tion of the pelvic ring, no bony reconstruction required for curative treatment.36 However, a infection risk and is crucial for the success of is essential.54,55 After tumor resection, patients limb preserving tumor resection must preserve the reconstruction procedure. Advances in with a stable bony pelvis can expect a much the femoral nerve, artery and vein and the microvascular free flaps, as in local rotational better postoperative function. Even without external iliac artery and vein.18,35 Extensive flaps, have extended the indications of limb- reconstruction of the acetabulum, a satisfying infiltration of the psoas muscle and an incau- sparing surgery and reduced local wound heal- functional result can be obtained.56 After a total tious biopsy can make resection or an internal ing problems. Finally, careful hemostasis and internal hemipelvectomy without reconstruc- hemipelvectomy impossible. The decision drainage should be carried out to avoid poor tion, a flail hip (unusually mobile joint) or a regarding surgical procedure and choice of wound healing.45,47 Bednar et al. assessed the floating hip can be the result. It is an alterna- adequate reconstruction method should take efficacy of tranexamic acid in decreasing oper- tive to amputation, but it leads to instability into account the patient's age, his personal ative blood loss and the need for intraoperative and leg shortening51,55 and is thus associated expectations, the demands on the function of transfusion in metastatic spine surgery but with poor function.57 This negative effect can the extremity but also the experiences of the could not shown any benefit of this prophylax- be avoided by an appropriate fusion between surgeon.17 Since reconstruction after tumor is.48 It has been observed that limb-saving sur- the femoral head and left pelvic bones.15

[Orthopedic Reviews 2011; 3:e4] [page 13] Article

Allografts in pelvic reconstruction cementing with or without an allograft69 as tion. A study by Abudu et al. 199776 describes Allografts are usually used to bridge bony indicated by Langlais et al.54 In their series, excellent to good results in 65% and satisfacto- defects after resection of parts of the iliac bone none of the patients suffered a relapse; all were ry to poor results in 35% of the patients. The with interruption of the pelvic ring (Type I pain-free and mobile without any walking complication rate was 60% (26% infections, resection), after resection of the acetabulum devices six months postoperatively. 15% dislocations, 6% bleeding, and 3% other). (Type II resection)58 or after resection of the Especially the fixation of these implants is anterior pelvic ring (Type III resection).59,60 The use of autografts technical demanding. Screw breakages or loos- The appropriate grafts can be calculated by CT After completion of the pelvic tumor resec- ening are frequently seen. Therefore, recon- scans while allografts provide an excellent tool tion reconstruction with autogenous grafts is struction of the pelvic ring by a metallic to reconstruct almost a normal pelvic anato- in order to establish a support between the implant only remains not useful. In contrast, a my.46,58 Here the graft can be modified surgical- acetabulum and the sacral bone.21 Grafts of stable fixation within the sacrum and / or ilium ly to fulfill into the complex geometry of the iliac crest bone and the vascularized or non- is recommended. Furthermore, an artificial corresponding osseous defect.22 Depending on vascularized fibula graft are commonly used to pelvis is not appropriate after resection of the the surgical technique, an intercalary allograft fill defects.70 Nagoya71 reported successful gluteal muscles.77 with or without arthrodesis, a composite allo- incorporations of vascularized fibulae in four The clinical results after implantation of graft or an osteochondral allograft reconstruc- patients after extensive periacetabular resec- saddle prosthesis are disappointing. Aboulatia tion can be used. The allograft allows bony tion. These patients were free of pain and et al. describe that 70% of their patients ingrowth of the recipient bone marrow cells none required walking aids. A drawback in the required crutches, three patients were immo- 46,51 and also reattachment of the muscles is use of autografts is mainly based on the limit- bile and the infection rate was high. Other quiet easier compared to metal implants.54 ed availability of the graft.16 In some centers authors report that saddle prostheses do not However, the disadvantages of this technique the tumor bone is excised, freed as far as pos- allow a sufficient range of motion. The lack in are the high risk of bone infections non- sible from the tumor, autoclaved for twenty bony integration and anchorage was also unions and allograft fractures.60 In a compre- minutes and re-implanted.72 In weight bearing described by O’Connor.15 In contrast, Van der hensive study with 945 patients the factors transplantation sites this approach is only rec- Lei19 reported on two patients significant ben- influencing the incorporation of the allograft ommended if the affected bone presents suffi- efit after saddle prosthesis was implanted. If were investigated. The non-union rate in their cient biomechanical properties.16 sufficient bony integration can be achieved the patient population amounts to 17.3%.62 Aho et saddle endoprosthesis allows full weight-bear- al. described best functional results using Reconstruction using arthroplasties ing minimizing comorbidity associated by knee osteoarticular allografts and clinical Proximal femoral megaprostheses can be immobilization. Moreover, patients can com- rejection did not occur.63 Some authors empha- used for the reconstruction of critical bone mence rehabilitation or postoperative chemo - size the lack of bone ingrowth of allo- defects after resection of the acetabular therapy earlier.19,78 grafts.41,46,55,61,62 Furthermore, the reconstruc- region18,22,73 as well as after internal partial or tion type has a high impact on the outcome total hemipelvectomy. Based on the limited Transposition of the remaining acetabulum after pelvic reconstruction: non-unions were number of patients and the high complication In the past twenty years, the transposition of more frequently seen when an allograft was rate after hemipelvectomy, a standard for the remaining acetabulum for hip reconstruc- applied for bone fusion compared to osteoartic- reconstruction with arthroplasties has not tion became popular. This method is especially ular, intercalary, or composite allografts. been established yet. Modular designs, cus- indicated after limited resection of the iliac Moreover, adjuvant chemotherapy treatment tom-made prostheses or conventional prosthe- bone and/or smaller parts of the cranial acetab- increased the rate of non-union.64 To prevent ses are available.74,75 A solid and stable fixation ulum. However, it is necessary that most parts infection and non-union, allografts should only of the endoprosthesis within the remaining of the acetabulum are still intact. One advan- be used in areas with adequate soft tissue cov- bone is a prerequisite for clinical success.18 tage is the good applicability in growing chil- erage.65 Malignant bone tumors, however, The advantages of prostheses are that they are dren. In such cases, the Y-shaped growth plate often complicate this condition because the available in a wide range of sizes. In addition, acts as a biological barrier for intra-osseous surrounding tissue has to be resected widely in cemented fixation allows immediately stability tumor growth.21,79 Acetabular transposition order to maintain the necessary safety dis- and early mobilization of the patients. also allows covering bony defect by muscles tance.63 The overall infection rate of allografts Regardless, megaendoprosthesis are associat- including the gluteus maximus in particular, used in general treatment of malignant or ed with several complications. Material failure but also parts of the gluteus medius and the aggressive lesions was only 10%.46 However, rates such as increased wear or fractures are gluteus minimus. Furthermore, it is possible to other studies reported higher infection rates more frequently seen than in primary joint reattach the abdominal and trunk muscles (25% and 33%).58,66 To reduce the risk for infec- replacement based on osteoarthritis. Also, the firmly to the rest of the acetabulum or an inter- tion, Windhager25 proposed that allografts reattachment of muscles is difficult leading to posed allograft.22 One disadvantage especially should be avoided in patients receiving high- high dislocation rates. Especially in cases of in children and adolescents is a relevant leg dose chemotherapy. limited or poor soft tissue coverage and length discrepancy66 and associated scolio- Nevertheless, it cannot be assumed that allo- immunosuppressed patients, there is a high sis.50,80 grafts guarantee a good functional outcome as risk of deep infection. In addition, total joint indicated by some authors.58,63 Aho63 rated the replacement may not appropriate in children Pseudarthrosis and arthrodesis after pelvic overall function as 57% only. O'Connor67 before the age of skeletal maturity.21 Here reconstruction achieved good to very good results in successful growing systems have been applied as an alter- The treatment of pseudarthrosis caused by sacro-iliac arthrodesis. However, non-solid native to achieve adequate limb length. surgical resection of relevant pelvic bone and fusion leads to limited and poor results. Puget68 pelvic reconstruction remains challenging. described fair results after reconstructing auto- Hemipelvic and saddle prostheses Therefore arthrodesis is an alternative treat- genous proximal femurs combined with total In severe acetabular bone defects leading to ment option. In a two-stage procedure, hip replacement. If no biological reconstruction pelvic discontinuity hemipelvic prostheses Hamdi81 fixed the femoral head transient to can be achieved sockets may be fixed by have been successful applied for reconstruc- the rest of the acetabulum and the iliac bone

[page 14] [Orthopedic Reviews 2011; 3:e4] Article and described good functional and oncological external hemipelvectomy using the hindfoot Table 1. Indications for external results. In a second procedure a neo-acetabu- rotationplasty with calcaneo-sacral fixation hemipelvectomy. 85 lum with sufficient stability is recommended. and described good functional results. Indications for external hemipelvectomy A similar method was presented by Kusuzaki.82 He attached the femoral head to the iliac bone Amputation and hemicorporectomy Destroyed biomechanics with an external fixator. Amputation is indicated if the tumor has Failed reconstruction of the pelvis (non-union, Sacro-iliac arthrodeses can be performed to destroyed biomechanical relevant areas, prosthetic loosening, prosthetic infection) bridge short distances between the sacrum reconstruction techniques have failed, or in Failed neoadjuvant therapy and the remaining part of the ilium after Type other patient related factors (Table 1). Severe deep infection 83 I resection. If the continuity of the pelvic ring But the indication for external hemipelvec- Infiltration of the sciatic nerve and the is sufficient, a sacro-iliac arthrodesis using an tomy should be strict and considered with care. femoravessels After external hemipelvectomy the stump can allograft in between the sacrum and ilium is Local recurrence of the tumor recommended.8,15,41 Arthrodesis of the femoral be covered by an anterior or a posterior gluteal Improvement of the resection margin head with the remaining acetabulum is flap and sutured with the inguinal ligament.87 described as a reconstructive option after com- A pelvic prosthesis basket can be used to Life saving procedure plete resection of the iliac bone.41,72 If the infe- enable patients to stand, sit and move after Palliative situation rior and medial parts of the acetabulum are unilateral amputation. But surgeons should be still intact to allow fixation of the femoral aware using this kind of mutilating surgery head, a hip arthrodesis with autogenous fibula because the technique is ambitious and the of achieving a good survivorship in limb saving or an allograft interposition can be applied. complication rate is very high. It should be 90,93 This method provides good stability with no known that this surgery is an extensive proce- surgery. The second prognostic factor is tumor size. The negative influence of large significant leg-length difference.55 For recon- dure. Due to the shorter convalescence time, struction after resection of Type I and Type II, this method is more likely to be chosen for eld- tumor mass (>200 mL) is documented for 6,91,94,95 a pubo-femoral41 or ischio-femoral arthrodesis erly patients.86 Complications of this method Ewing sarcoma and osteosarcoma. has been suggested,2 while after resection of often appear later. These include shoulder pain Metastatic sarcomas are known to have a sig- Type II and Type III, an ilio-femoral arthrodesis from walking with sticks, scoliosis due to tilt- nificantly worse prognosis than localized dis- 91,96 is recommended.2,41 This results in complete ing of the pelvis or arthrosis in the hip or knee ease. The third important factor for sur- immobility of the hip joint, which is, however, of the contralateral leg.88 vivorship and functional outcome is the resec- opposed to a good stability without pain.22 Van Hemicorporectomy involves amputation of tion margin. In a study by O’Connor et al., the der Lei19 observed leg shortening and an the pelvis and the lower extremities by dysar- general local recurrence rate of all cases after impaired gait pattern in his patients after ilio- ticulation through the lumbar spine. Barnett et R0 resection was 17%. This occurs in 47% of femoral arthrodesis. In contrast, Enneking41 al. stated that this extensive procedure is well patients after marginal resection, but only in showed that there was no significant leg- tolerable in paraplegic patients with dissemi- 8% after wide resection. Wide resection allows length discrepancy. O'Connor15,83 favors ilio- nated pelvic tumors or pelvis osteomyelitis and a satisfactory surgical procedure without posi- femoral arthrodesis with direct attachment of improves greatly the quality of life of these tive microscopic resection margin.83 Tomeno the femoral head to the iliac bone. He recom- carefully selected patients.89 showed a local recurrence rate after inade- mended this technique for young and active quate (combination of marginal and intrale- patients. A disadvantage of the ilio-femoral Oncological results sional resection) resection of 67%, after wide and ischio-femoral arthrodesis is the mobility In addition to the tumor entity and the pre- resection the rate was only 4%.97 Some of the symphysis with subsequent instability of operative stage, three factors play a specific authors25,78,98 emphasize the technical difficul- the pelvic ring and femur abduction.41,55 role for the prognosis of pelvic bone tumors: ty to achieve a wide surgical margin (33%, the tumor location, the tumor size and the 65%, 22%) in the pelvis. Since the real tumor Femoral and hindfoot rotationplasty resection margin.5 extent is often underestimated98 and intra- Winkelmann distinguishes different types of An important factor for the local recurrence lesional and marginal tumor removal should be rotationplasty. Pelvic tumors require not only rate is the location of the primary tumor. Some avoided a correct staging including MRI and the resection of the pelvic site but also to some authors found higher recurrence rates for CT scans, a preoperative planning, as well as extend the proximal femur. One option to tumors in the periacetabular region and in the intraoperative histology of soft tissue is essen- achieve fair function is to rotate the remaining pubic bone.15,76 Other authors reported recur- tial. Besides different vessels, the bladder, the femur of 180° and fix it to the ilium. If the rence rates of 50% after sacro-iliac resections peritoneum and the ilio-sacral joint are critical femur needs to be completely resected, e.g. in and 15-24% after acetabular resection.43,90 For areas. Especial in tumors next to the symph- children, the lateral tibial plateau can articu- Ewing sarcoma Hoffmann91 observed a survival ysis, the real extent of the tumor is underesti- late in the remaining hip socket and gradually rate of 45% after resection of the infiltrated mated quiet often and technical demanding.99 re-forms into a replacement femoral head. sacrum, 43% survival rate after resection of the However, if the ankle joint acts as the new iliac bone and 51% after resection of the Metastases and recurrence rate of knee, the lower leg is replaced by a prosthesis. acetabulum. In the sacrum or ilium there is In adults, total femur replacement including apparently a high risk of leaving contaminated the entities and survival after treatment the knee joint is an alternative to rotationplas- R1 or R2 resection margins. If a wide resection Sheth et al. described distant metastases ty. The advantages of this procedure are excel- cannot be achieved and the tumor is irradia- rates of between 60% and 75% in Grade 2-3- lent function and preserved proprioception. In tion-sensitive, perioperative radiotherapy chondrosarcomas.100 Overall, the general distant addition, no further surgery is required. The should be applied to reduce the tumor volume. metastases rate ranges from 13.3-28%.41,50,57,106 disadvantage is the psychological burden Micrometastases at the resection margins may The local recurrence rate after resection of imposed on the patient by the external appear- also be eliminated by postoperative irradia- malignant pelvic tumors range approximately ance and cosmetic issues.84 Kong et al. pre- tion.91,92 Furthermore, intraoperative brachy - from 4-50 % (5, 41, 50, 67, 76, 77, 97, 100, 101, sented a new reconstruction method after therapy has shown promising results in terms 102, 103, 104, 105, 106, 107 is shown in Table

[Orthopedic Reviews 2011; 3:e4] [page 15] Article

2. However, the overall survival rate in Ewing's Table 2. Local recividism rate after hemipelvectomy of different entities. sarcoma patients is still significantly lower 4 (57% in 3.7 years) than in patients with osteo- Authors Year Entity Total Type I Type II Type II (%) (%) (%) (%) or chondrosarcoma.2,100 The effectiveness of surgical treatment for Ewing's sarcoma of the Eneking et al.41 1978 Primary neoplasms of the pelvis 28 pelvis is higher compared to chemotherapy Tomeno97 1987 Malignant tumors of the iliac bone 21 21 and/or radiotherapy. The data on survival in Ewing’s sarcoma vary between 39% and 52% in O`Connor et al.67 1989 Malignant pelvic tumors 17 11 (38) 8 20 five years, 44% in ten, and 32% in twelve Guest et al.101 1990 Bone sarcomas 30 5,91,108 77 years. Uchida describes a five-year sur- Dunst et al.102 1991 Ewing sarcomas 50 vival rate of only 50% after resection of acetabular tumors; Abudu76 reported a postoperative Donati et al.103 1993 Malignant pelvic tumors 24 24 survival rate of 43% within seven years. In the Shin et al.104 1994 Bone sarcomas 4 5 study by Kawai, 55% of the patients are still Abudu et al.76 1997 24 24 alive after 5 years and 87% were in complete Cannon et al.105 1995 Primary bone tumors of the ilium 24 24 remission. Likewise, Uchida reported a five- year survival rate of 50%,76 The prognosis Sheth et al.100 1996 Chondrosarcoma 28 depends also on the differentiation stage of a COSS-9628 1996 Osteosarcoma 4-10 tumor describing the degree of malignancy. 77 With highly malignant bone tumors, it is diffi- Uchida et al. 1997 Malignant bone tumors 30 30 cult to achieve both local and also systemic Kawai et al.5 1998 Osteosarcoma 32 control of the disease. According to general Bjornsson et al.106 1998 Chondrosarcoma 19.7 opinion, simple resection of highly malignant Pring et al.50 2001 Chondrosarcoma 19 bone tumors should only be addressed after careful preoperative staging, interdisciplinary Donati et al.107 2009 Chondrosarcoma 17-41 workup and critical assessment of the effectiveness of the procedure. However, simple resection may be considered in aggressively Clin N Am. 2005;14:633-48. benign and low-malignant bone tumors.108 References 10. Ozaki T, Hillmann A, Lindner N. Chondrosarcoma of the Pelvis. Clin 1. Apffelstaedt JP, Driscoll DL, Spellmann JE, Orthop Rel Res 1997;226-39. et al. Complications and Outcome of 11. Carter SR, Eastwood DM, Grimer RJ, Conclusions external hemipelvectomy in the manage- Sneath RS. Hindquarter Amputation for ment of pelvic tumors. Ann Surg Oncol Tumors of the Muskuloskeletal System. J The prognosis of primary malignant bone 1996;3:304-9. 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