The Journal of Arthroplasty 28 (2013) 537542

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The Journal of Arthroplasty

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Composite Reconstruction of the Hip Following Resection of Periacetabular Tumors

Middle-Term Outcome
Sujia Wu MS, Xin Shi MS, Guangxin Zhou PhD, Men Lu MS, Chengjun Li MS
Department of Orthopedics, Jin Ling Hospital, Nanjing, Jiangsu Province, P.R. China

a r t i c l e

i n f o

Article history:
Received 13 July 2011
Accepted 13 August 2012
Keywords:
periacetabular tumors
hip reconstruction
surgical outcome
limb salvage surgery

a b s t r a c t
The records of 18 patients with periacetabular tumors who underwent composite reconstruction of the hip
following resection of periacetabular tumors were analyzed retrospectively. The mean follow-up period
was 49.4 months (range, 28100 months). During follow-up, 3 patients died and one had recurrence.
Fifteen patients achieved favorable walking function; 8 had normal hip function and 7 had partial recovery
of exion function of the hip. The mean MSTS rating for hip function was 76.9%. Two patients had common
peroneal nerve injury which was resolved in one of them. Middle-term follow-up showed that composite
reconstruction of the hip following resection of periacetabular tumors can effectively remove tumors and
provide favorable hip function for these patients. This approach is simple and less costly, and can be
widely used.
Crown Copyright 2013 Published by Elsevier Inc. All rights reserved.

Pelvic malignant tumors account for 34% of all malignant bone

tumors [1,2]. Because of the availability of more effective chemotherapy, limb salvage surgery increasingly has become a treatment option.
However, periacetabular tumors present a difcult surgical challenge.
Reconstruction is necessary for limb salvage, but the greater the
extent of surgery the more difcult is reconstruction and the more
prevalent are complications including infection, nerve palsy, neuropraxia, perioperative fracture, heterotopic ossication, deep vein
thrombosis, and local recurrence [1,36].
Recently, signicant progress has been made in the surgical
treatment of periacetabular tumors. There are three main types of
reconstructive surgery that are currently used: megaprosthesis
implantation, saddle prosthesis, and massive allografts [7]. Megaprosthesis implantation provides immediate reconstruction, and in
the short term there are only limited mechanical complications, but
there is a high rate of major complications including infection,
loosening, and dislocation. Also, it provides a poor functional result
after hemipelvic resection, and is expensive [7,8]. The saddle
prosthesis is a simpler method and provides better maintenance of
hip stability and limb length, however, a review of outcomes of
patients who had pelvic sarcoma reconstruction with a saddle
prosthesis showed that this procedure is associated with considerable
morbidity and complications such as infection and loosening [6,8].
Massive allografts have the advantage of providing anatomical
reconstruction and an osteoarticular allograft, but have been limited
The Conict of Interest statement associated with this article can be found at http://
dx.doi.org/10.1016/j.arth.2012.08.015.
Reprint requests: Sujia Wu, MS, Department of Orthopredics in Jin Ling Hospital,
305 Zhong Shan East Road, Nanjing 210002, Jiangsu Province, P.R. China.

by fractures, transmission of infectious diseases, and lack of

incorporation in the long term [8].
Despite the progress in surgically treating periacetabular tumors,
the mortality, complication, and recurrence rates are still relatively
high [6,9]. Our procedure of composite reconstruction was developed
to be simpler to perform and less costly. It does not involve any
custom-made equipment, requiring only an ordinary reconstruction
plate, xing screws, wires, and bone cement. The present study aimed
to review our experience of using composite reconstruction.
Methods
General Information
This retrospective study included 18 patients with periacetabular
tumors who underwent composite reconstruction of the hip following
the removal of tumors at the Department of Orthopaedics of our
hospital from May 2001 to May 2008. There were 11 male and 7 female
patients; their mean age was 44.5 years (range: 1571 years) (Table 1).
Six patients had chondrosarcoma, 3 had giant cell tumor of the bone, 3
had osseous metastasis, 2 had lymphoma, 2 had osteosarcoma, 1 had
malignant brous histiocytoma, and 1 had malignant primitive
neuroectodermal tumor (Table 1). All patients were diagnosed at
their initial visit, The patients were selected for surgery if they met the
following inclusion criteria: 1) Their general condition was suitable for
limb salvage surgery. Pre-operative computerized tomography (CT),
magnetic resonance imaging (MRI), and angiography were carried out
to determine the tumor boundary for surgical removal. 2) A surgical
safety margin could be achieved where semi-pelvic amputation would
be performed. 3) Local resection and reconstruction could assure the

0883-5403/2803-0029$36.00/0 see front matter. Crown Copyright 2013 Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.arth.2012.08.015

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S. Wu et al. / The Journal of Arthroplasty 28 (2013) 537542

Table 1
Demographics, Clinical Status, Limb Function, Complications, Tumor Type and Tumor Location For 18 Patients who Underwent Composite Reconstruction of the Hip.

No. Age (y) Follow-Up (mo) Recurrence

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

17
52
71
53
15
52
61
46
54
48
34
20
47
34
48
42
36
71

Status

48
No
Tumor free survival
23
Yes
Death
17
Yes
Death
52
No
Tumor free survival
62
No
Tumor free survival
44
No
Alive but not tumor free
100
No
Tumor free survival
28
No
Alive but not tumor free
Death (pulmonary embolism)
62
No
Tumor free survival
80
No
Tumor free survival
31
No
Alive but not tumor free
48
No
Tumor free survival
19
Yes
Alive but not tumor free
49
No
Tumor free survival
15
No
Tumor free survival
66
No
Tumor free survival
96
No
Tumor free survival

Disease Condition MSTS Score (%) MSTS Pain Component Complication

Excellent
Intermediate
Inferior
Excellent
Excellent
Good
Excellent
Excellent

87.3
54.7
32.5
91.3
85.4
79.2
90.7
86.3

4.2
3.5
1.8
4.8
4.3
4.0
4.6
4.5

no
no
no
no
DWH
no
no
DWH

Good
Excellent
Good
Excellent
Intermediate
Good
Good
Good
Excellent

81.3
88.0
69.1
89.8
58.8
78.7
71.9
69.3
92.6

4.0
4.4
3.5
4.5
3.0
4.0
3.7
3.5
4.6

DWH
NI
no
no
no
NI
DWH
no
no

Tumor
Type

Enneking
Zone

LAL
II
LMA
II + partial I
LAL
II
LAC
II
LAPN
II
LAO
II + partial III
LAC
II
LMA
II + partial I
RAC
II + III
RAGCTB II + partial I
RAC
II
RAO
II
RAMFH II + partial I
LAC
II + partial III
RAGCTB
II
RAC
II
LAGCTB
II + III
RMA
II

DWH = delayed wound healing; NI = nerve injury; LAL = left acetabular lymphoma, LMA = left metastatic acetabular; LAC = left acetabular chondrosarcoma; LAPN = left acetabular
primitive neuronectodermal; LAO = left acetabular osteosarcoma; RAC = right acetabular chondrosarcoma; RAGCTB = right acetabular giant cell tumor of bone; RAO = right
acetabular osteosarcoma; RAMFH = right acetabular malignant brous histiocytoma; RAGCTB = right acetabular giant cell tumor of bone; RMA = right metastatic acetabular.

preservation of proper functions. Post-operative pathological examination conrmed the diagnosis of periacetabular tumors. Patients were
not treated surgically if 1) the tumors extensively invaded the soft
tissues, major blood vessels, or nerves in the pelvis; or 2) their general
condition was too poor to undergo surgery.

(6) The femoral head was removed, and then the body and stem of the
femoral head prosthesis (prepared with bone cement) were inserted
into the proximal femur (Fig. 8). Manual reduction of the hip
prosthesis was carried out and the reconstruction was completed.
Postoperative Treatment Plan

Preparation for Surgery

Embolization was performed in all patients 2448 hours before
surgery. For patients with giant cell tumor, metastatic tumors or large
tumors protruding into the pelvic cavity, ligation of the bilateral
internal iliac arteries was carried out prior to surgery.

The patients were asked to remain in bed for 2 months after

surgery. After this initial recovery period of 2 months they were
instructed to walk with crutches. Following this second 2-month
period the patients were allowed to walk without crutches when they
were able to do so.
Assessment of Outcome

Surgical Procedures
After complete removal of periacetabular tumors (Fig. 1), the
following procedures were carried out for reconstruction: (1) At least
four cancellous bone screws (6 mm in diameter and 610 cm in
length) were inserted into the residual ilium, residual pubis, and
ischiadic ramus in different directions, respectively. The screw shanks
were left about 23 cm in the space previously occupied by the
resected acetabulum. The number of screws depended on the size of
the resected periacetabular tumor (Fig. 2). Sometimes we had to
insert more than four screws because the purpose of the these screws
was not only to make sure the position of the prosthesis was
maintained but also to provide stability for the prosthesis. (2) The
next step was to place a test model of the prosthesis to adjust the
direction of the screws and decide on the nal position of the
prosthesis (Fig. 3). Additionally, we had to make sure that the tips of
the screws were in contact with the top of the prosthesis. (3) The next
step was to use a reconstruction plate to connect the residual ilium,
residual pubis, and ischiadic ramus (Figs. 4 and 5). This step was not
denitely necessary and was determined by the size of the resected
acetabular tumor. If the distance between the residual ilium, pubis
and ischium was too far and these residual bones were too small, then
the plate was necessary. Otherwise, inserting more screws could also
maintain plate stability. This was the case for the patient in Fig. 6 who
received more than four screws and no plate was used. (4) Next, wires
(1 mm in diameter) were wound around the reconstruction plate and
the xing screws. (5) The acetabular prosthesis, reconstruction plate,
and screws were integrated by bone cement, which was applied to
reconstruct the resected acetabulum and its surrounding area (Fig. 7).

Functional outcome following reconstruction was assessed by

using the Musculoskeletal Tumor Society (MSTS) evaluation system
(1993 version) [10]. This system is based on analysis relevant to

Fig. 1. After tumor resection.

S. Wu et al. / The Journal of Arthroplasty 28 (2013) 537542

539

Fig. 2. First step of the reconstruction of acetabulum.

Fig. 4. Plate used to connect the residual iliac bone, pubic bone and ischial bone.

general factors (pain, restriction of activities and/or occupation, and

emotional acceptance) and factors specically related to the affected
limb (use of walking supports, walking ability, and gait). The overall
result is expressed as a percentage of maximum possible score [11].
During the rst 3 years after surgery the patients were evaluated
every 36 months and thereafter annually.

The operation time ranged from 2.5-4 hours. Intraoperatively,

blood pressure was controlled and the mean arterial pressure
remained at 4060 mmHg during the 3040 minutes for tumor
resection. The volume of blood for transfusion was about 10004000
ml. The mean length of hospital stay was 10 days. The mean follow-up

period was 49.4 months (range: 28100 months). The Enneking

zone(s) affected by tumor for each patient is listed in Table 1. Every
patient had zone II tumor and some patients also had tumor in zone I
or III. Three patients died during the follow-up period. One patient
who had osteosarcoma died intraoperatively due to bilateral
pulmonary embolism, another with highly malignant mesenchymal
chondrosarcoma had recurrence and distant metastasis at 23 months
after surgery, and the third patient who had metastatic tumor had
systemic failure at 17 months after surgery. One patient with giant cell
tumor was lost to follow-up at 15 months after surgery. All patients
were bedridden for 2 months. After the 2 months the patients could
walk with crutches with partial weight-bearing. About 46 months
after surgery the patients could walk without crutches. Nine of the
patients were able to walk almost normally and the other 9 had
abductor lurch but could still walk without any aids and without
distance being limited. Eight patients had normal exion and

Fig. 3. Test model of prosthesis put in place.

Fig. 5. Wires wound around the plate and screws.

Results
Surgical Outcome

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S. Wu et al. / The Journal of Arthroplasty 28 (2013) 537542

Fig. 6. A typical case. (A) radiography before surgery; (B) radiography after surgery; (C) radiography 2 years after surgery; (D) radiography 4 years after surgery; (E) radiography 6
years after surgery; (F) limb function 6 years after surgery.

extension of the hip and 7 patients had mean exion of the hip of
0100 degrees (Fig. 6). Although some patients had a 15 degree
difference of exion in the operated hip compared with the opposite
normal hip, this had no effect on hip function or daily activity.

patients with better than good outcome was 77.8% (Table 1). The
mean pain component score of the MSTS was 3.9.

Complications

Traditionally, hemipelvectomy has been used for the treatment of

pelvic tumors. However, because this surgical procedure is extremely
invasive and has the possibility of causing disability, it is usually
unacceptable for some patients [12]. In the past 20 years, with
developments in diagnosis, pathology, and surgery and the introduction of neoadjuvant chemotherapy and establishment of principles for
surgical removal of tumors, hemipelvectomy has been replaced with
new methods. In 1978, Steel [13] rst reported internal hemipelvectomy in patients with pelvic tumors. In this surgery, the femoral head
preserved and excluded from resection, and the scar and surrounding
muscles were used to stabilize the femoral head which salvaged the
functions of the lower limbs. However, this approach has the
disadvantages of resulting in an unstable affected hip, shortness of
affected limbs, and obvious lameness. Although Kusuzaki et al [14]
applied exclusion, they used external xation support to x the hip
and femur for 6 weeks and the femoral head was stabilized by the

Two patients had post-operative common peroneal nerve injury

(Table 1). In one patient this condition resolved after 6 months
whereas the other patient still suffered from the peroneal nerve injury
during follow-up and used a brace for protection. Four patients had
delayed wound healing which resolved after standard dressing was
refreshed. There were no other complications such as infection,
dislocation, or incisional hernia.
Functional Outcome
Musculoskeletal Tumor Society ratings were obtained for all
patients except for one who died. The mean MSTS rating was 76.9%.
Eight patients had excellent outcome, 6 had good outcome, 2 had
intermediate outcome, and 1 had inferior outcome. The proportion of

Discussion

S. Wu et al. / The Journal of Arthroplasty 28 (2013) 537542

Fig. 7. Cement added.

surrounding scars. In the 1990s, the saddle prosthesis was developed

by the Link Company. It has the advantage of a simple operation and
patients can walk as soon as possible. However, the abrasion between
the prosthesis and the contact area of the hip, the movement of the
prosthesis upward, and shortness of the affected limbs have been
noted after reconstruction with a saddle prosthesis [6,15]. In addition,
some surgeons obtained and then autoclaved the resected acetabulum which was then re-implanted [16]. But complications and nonhealing are the concerns with this approach. There does not appear to
be any evidence that there is a difference in behavior between
autoclaved massive grafts and allografts of the same size [16]. In
recent years, some other methods have been attempted for the
reconstruction of the hip following removal of periacetabular tumors.
For example, Parikh et al. [17] inserted Steinmann pins to achieve a
high density of pins and then used bone cement and a hip prosthesis
for the reconstruction of the acetabulum and obtained favorable
outcomes. However, the sample size of their study was small and
patients walked only with the aid of walkers. Another method that has
been tried is ipsilateral femoral autograft reconstruction [8]. This
method involves transposing the proximal part of the femur into the
defect and implanting a conventional total hip replacement in the
autograft. It is a possible option for treating patients with a zone-II or a
combined zone-II and -III pelvic defect. However, mechanical failure
can occur and this method is associated with the complications of
infection and local recurrence. We used our method mainly for tumor
in Enneking zone II but also we used it for patients with tumor in zone
II and partial zone I or partial zone III or zone II and III.
The patients in our study who underwent composite reconstruction were followed up for about 4 years, and favorable outcome and
hip function after surgery were generally noted. Eight (44.4%) patients
had normal exion and extension of the hip. In our study, the survival
rate was 83.3%, the recurrence rate was 5.5%, the mean MSTS rating
was 76.9%, and the mean score of the pain component of the MSTS
was 3.9 (3 indicates modest pain but not disabling and 4 indicates
intermediate pain between no pain and modest pain). The advantages
of this approach included: (1) the procedure is simple, and applicable
for acetabular surgery of different extents and exibility; (2) a general
prosthesis prepared from bone cement and a commonly used plate
and screws and wires were used in the reconstruction and it is not
necessary to prepare a custom-made pelvic prosthesis. Therefore, the
patients can be treated in a timely manner, which is also a surgical

541

principle; (3) the cost of materials used in the reconstruction is less,

thereby making this surgery feasible in poorer developing countries;
(4) periacetabular tumors usually invade the acetabulum, partial
ilium, partial pubis, and ischium. Therefore, these bones in combination with the obturator ring should be removed during surgery. For
patients with zone II and partial zone III tumor it was important to
make sure that all screws at the acetabulum be placed at the iliac
bone. When a large portion of ilium is involved, the screws should be
inserted into the sacroiliac joint. However, excessive removal of the
pubis and ischium will make the insertion of screws difcult and the
acetabulum will receive the force from the xed screws and bone
cement. However, the patients will still have walking function.
Our composite reconstruction procedure generally resulted in
fewer complications and better functional outcomes than other types
of procedures. Of note is that no patient in our study had infection or
dislocation and only one patient had recurrence. Also, the MSTS rating
was 76.9%. Jaismal et al. [9] studied 98 patients who received a custommade prosthesis. They reported a 5-year survival rate of 67% and a local
recurrence rate of 31%. One third of the patients died and 58.1% had
least one complication. Six patients had femoral nerve palsy after
surgery. In a study by Guo et al., [8] 28 patients were given a
hemipelvic prosthesis. The overall survival rate at 3 years was 67.1%,
the local recurrence rate was 25%, and the mean MSTS rating was 60%.
No patients were reported to have nerve palsy postoperatively. Aljassir
et al. [6] studied 27 patients who received a saddle prosthesis. The
patients were followed up for 45 months. The survival rate was 60%,
the local recurrence rate was 22%, and the MSTS rating was 51%. There
were 5 patients who had nerve palsy. It is unclear why our procedure
appeared to result in fewer complications and better functional
outcomes. Patient age does not seem to be a factor. Our patients
were about the same age as the patients in the study by Jaiswal et al. [9]
(mean age 44.5 years and 43.6 years, respectively) and were older than
those in the study by Guo et al. [8] (median age, 38 years) and younger
than those in the study of Aljassir et al. [6] (mean age, 53 years). Jaiswal
et al. [9] did not use the MSTS evaluation system, making comparisons
more difcult between studies. We speculate that our simpler surgical
procedure of composite reconstruction may have resulted in fewer
complications and better functional outcomes.
Our study was limited by its retrospective design, Also, only
relatively few patients have undergone this surgery. Follow-up,
however, has been performed for a considerable period of time. The

Fig. 8. The body and stem of the femoral head prosthesis inserted.

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S. Wu et al. / The Journal of Arthroplasty 28 (2013) 537542

existing data suggest that this approach used in the treatment of

periacetabular tumors provides favorable outcomes. However, the
biomechanical evidence for this approach is still lacking and further
studies will be needed. Finally, the longest follow-up period was 100
months, which although long for a cancer patient may not be of
sufcient duration to determine whether this approach would remain
mechanically viable in the long term.
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