Acetabular Reconstruction With Femoral Head Autograft After Intraarticular Resection of Periacetabular Tumors is Durable at Short-term Followup

Abstract

Background: Pelvic reconstruction after periacetabular tumor resection is technically difficult and characterized by a high complication rate. Although endoprosthetic replacement can result in immediate postoperative functional recovery, biologic reconstructions with autograft may provide an enhanced prognosis in patients with long-term survival; however, little has been published regarding this approach. We therefore wished to evaluate whether whole-bulk femoral head autograft that is not contaminated by tumor can be used to reconstruct segmental bone defects after intraarticular resection of periacetabular tumors.

Questions/purposes: In a pilot study, we evaluated (1) local tumor control, (2) complications, and (3) postoperative function as measured by the Musculoskeletal Tumor Society score.

Methods: Between 2009 and 2015, we treated 13 patients with periacetabular malignant or aggressive benign tumors with en bloc resection, bulk femoral head autograft, and cemented THA (with or without a titanium acetabular reconstruction cup), and all were included for analysis here. During that time, the general indications for this approach were (1) patients anticipated to have a good oncologic prognosis and adequate surgical margins to allow this approach, (2) patients whose pelvic bone defects did not exceed two types (Types I + II or Types II + III as defined by Enneking and Dunham), and (3) patients whose medical insurance would not cover what otherwise might have been a pelvic tumor prosthesis. During this period, another 91 patients were treated with pelvic prosthetic replacement, which was our preferred approach. Median followup in this study was 36 months (range, 24-99 months among surviving patients; one patient died 8 months after surgery); no patients were lost to followup. Bone defects were Types II + III in five patients, and Types I + II in eight. After intraarticular resection, ipsilateral femoral head autograft combined with THA was used to reconstruct the segmental bone defect of the acetabulum. In patients with Types I + II resections, the connection between the sacrum and the acetabulum was reestablished with a fibular autograft or a titanium cage filled with dried bone-allograft particles which was enhanced by using a pedicle screw and rod system. Functional evaluation was done in 11 patients who remained alive and maintained the femoral head autograft at final followup; one other patient received secondary resection involving removal of the femoral head autograft and internal fixation, and was excluded from functional evaluation. Endpoints were assessed by chart review.

Results: Two patients experienced local tumor recurrence. Finally, eight patients did not show signs of the disease, one patient died of disease for local and distant tumor relapse, and four patients survived, but still had the disease. Three of these four patients had distant metastases without local recurrence and one had local control after secondary resection but still experienced system relapse. We observed the following complications: hematoma (one patient; treated surgically with hematoma clearance), delayed wound healing (one patient; treated by débridement), deep vein thrombosis (one patient), and hip dislocation (one patient; treated with open reduction). The median 1993 Musculoskeletal Tumor Society score was 83% (25 of 30 points; range, 19-29 points), and all patients were community ambulators; one used a cane, three used a walker, and nine did not use any assistive devices.

Conclusions: In this small series at short-term followup, we found that reconstruction of segmental bone defects after intraarticular resection of periacetabular tumors with femoral head autograft does not appear to impede local tumor control; complications were in the range of what might be expected in a series of large pelvic reconstructions, and postoperative function was generally good.

Level of evidence: Level IV, therapeutic study.

Fig. 1

The types of pelvic resections, as described by Enneking and Dunham [8], are shown.

Fig. 2A–D

A pelvic reconstruction with an ipsilateral femoral head autograft is presented. (A) The ipsilateral femoral head is harvested and fixed to the residual ilium after Types II + III pelvic resection. (B) A cemented THA is performed to maintain joint function. (C) After a Types I + II pelvic resection, the acetabulum and continuity of the pelvic ring are reestablished by the ipsilateral femoral head combined with fibular autografts. (D) The hip is replaced by a cemented endoprosthesis.

Fig. 3A–H

A female patient (Patient 10) with pelvic dedifferentiated chondrosarcoma underwent femoral head autograft reconstruction. (A) Her preoperative plain radiograph and (B) T2-weighted MR image show involvement of the ilium and superior part of the acetabulum. (C) An intraoperative view shows the pelvic ring is reconstructed with a double nonvascularized fibular autograft (one arrow) and femoral head autograft (two arrows) enhanced by cancellous compression screws and a spinal pedicle screw-rod system. (D) A postoperative plain radiograph and (E) CT scan obtained at the 24-month followup show good local tumor control with no signs of mechanical failure of the endoprosthesis or internal fixation. (F) This patient could stand and (G) squat freely without aid at her 24-month followup.

Fig. 3A–H

A female patient (Patient 10) with pelvic dedifferentiated chondrosarcoma underwent femoral head autograft reconstruction. (A) Her preoperative plain radiograph and (B) T2-weighted MR image show involvement of the ilium and superior part of the acetabulum. (C) An intraoperative view shows the pelvic ring is reconstructed with a double nonvascularized fibular autograft (one arrow) and femoral head autograft (two arrows) enhanced by cancellous compression screws and a spinal pedicle screw-rod system. (D) A postoperative plain radiograph and (E) CT scan obtained at the 24-month followup show good local tumor control with no signs of mechanical failure of the endoprosthesis or internal fixation. (F) This patient could stand and (G) squat freely without aid at her 24-month followup.

Fig. 4

A patient’s (Patient 11) postoperative plain radiograph shows that the connection between the sacrum and the new acetabulum was reestablished by a titanium cage combined with a pedicle screw and rod system.