Journal of Orthopaedic Surgery 2006;14(2):155-62
Pelvic reconstruction using saddle prosthesis
following limb salvage operation for
periacetabular tumour
Y Kitagawa, ET Ek, PFM Choong
Department of Orthopaedics, University of Melbourne, Department of Surgery, St Vincent’s Hospital Melbourne, Victoria,
Australia
ABSTRACT
Purpose. To assess the clinical results of pelvic
reconstruction using a saddle prosthesis following
limb salvage operation for periacetabular tumour.
Methods. 12 patients with sarcoma and 4 with
metastasis involving the pelvis were treated using the
saddle prosthesis between 1995 and 2003 inclusive.
Wide pelvic resection was performed for all patients
with sarcoma and one with a metastatic lesion;
intralesional excision of the acetabulum was
undertaken for the remaining 3 patients with
metastatic lesions. Oncologic prognosis, operation
time, postoperative function, and complications were
assessed retrospectively.
Results. Of the 12 patients with sarcomas, 5 were alive
without evidence of recurrence after a mean followup of 37 months, one was alive with disease, 3 died of
the disease, and 3 of other medical conditions.
Respective mean postoperative functional scores
according to the Musculoskeletal Tumor Society–
International Symposium on Limb Salvage system and
the Toronto Extremity Salvage Score were 53 and 64%
in patients undergoing wide acetabular resection, and
30 and 42% in patients undergoing intralesional
excision of the acetabulum. In patients undergoing
wide acetabular resection and intralesional excision of
the acetabulum, the mean operation times were 391
and 162 minutes respectively, whereas the mean times
to ambulation were 7 and 4 days respectively. Major
complications included infection and dislocation.
Conclusion. Saddle prosthesis arthroplasty is a useful
option for pelvic reconstruction following resection of
acetabular malignancies. It is associated with a short
operation time, rapid recovery, and moderately good
postoperative function, but a relatively high risk of
complications.
Key words: acetabulum; limb salvage; neoplasm metastasis;
prostheses and implants; reconstructive surgical procedures;
sarcoma
Address correspondence and reprint requests to: Prof Peter FM Choong, Department of Orthopaedics, St Vincent’s Hospital
Melbourne, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia. E-mail: [email protected]
Journal of Orthopaedic Surgery
156 Y Kitagawa et al.
INTRODUCTION
Limb salvage surgery is the treatment of choice for
malignant tumours of the extremities. For pelvic
tumours, however, such surgery remains controversial
due to the higher risk of haemorrhage, nerve and
visceral damage, and infection. 1,2 Periacetabular
tumours present a particular challenge, because of their
potential impact on limb function.3 Although several
reconstructive procedures have been reported,
including pelvic prosthesis arthroplasty, allograft
reconstruction (with or without a total hip prosthesis),
arthrodesis, and pseudarthrosis, a ‘gold standard’ has
yet to be established due to poor postoperative
function and high complication rates.
The saddle prosthesis,4 originally developed for
revision of failed total hip arthroplasty, has been used
as a reconstruction device for large bone defects
following resection of periacetabular malignant
tumours. It is unclear whether the saddle prosthesis
arthroplasty improves postoperative function and
reduces complications, as the number of large case
studies is limited.5–8
We assessed the clinical results of pelvic
reconstruction using the saddle prosthesis following
limb salvage operations for periacetabular tumour.
MATERIALS AND METHODS
Over the period 1995 to 2003 inclusive, 16 patients with
malignant tumours around the acetabulum attended
St Vincent’s Hospital Melbourne, Australia, and had a
saddle prosthesis (Link, Hamburg, Germany) inserted.
Their clinical data are presented in Table 1. The mean
age of these 5 men and 11 women was 61 years (range,
26–72 years). The diagnoses were bone sarcoma
(patients 1–11), soft-tissue sarcoma (patient 12), and
metastasis (patients 13–16). Histologically, the tumours
included: chondrosarcomas, osteosarcomas, a spindle
cell sarcoma, malignant fibrous histiocytomas, a
fibrosarcoma of the buttock, and metastases from
primaries in the kidney, prostate, and uterus (Table
1). According to the Enneking’s staging system, 9
patients 1, 2, and 5 were classified as IB and patients 3,
4, and 6 to 12 as IIB.
Perioperative data, oncologic results, and
postoperative complications were retrieved from
operation reports and medical records. There were no
exclusion criteria.
Pelvic resections were classified according to
Enneking’s system,10 which divides the pelvis into 4
regions: P1 (ilium), P2 (periacetabulum), P3 (pubic
rami), and P4 (hemisacrum); and the hip into 3 regions:
H1 (epiphysis of the proximal femur), H2 (metaphysis
of the proximal femur), and H3 (diaphysis of the
femur). The functional status of the hip abductor
mechanism was classified as A (intact) or B (disrupted).10
Reconstruction using the saddle prosthesis was
performed in all 16 patients (Fig. 1). The surgical
technique has been previously described.4
Postoperative function was evaluated at the final
follow-up using: the Musculoskeletal Tumor Society–
International Symposium on Limb Salvage system
(MSTS-ISOLS), 11 the Toronto Extremity Salvage
Score (TESS),12 and the scoring system for saddle
prosthesis arthroplasty.5 The MSTS-ISOLS consists of
6 factors (pain, function, emotional acceptance,
support, walking, and gait). The score is converted to
a percentage and the highest score is 30.11 TESS is a
questionnaire that assesses daily-living functions in
patients who undergo limb salvage surgery for bone
and soft-tissue sarcomas of the extremities. It consists
of 30 activities, and the score is converted to a
percentage.12 The scoring system for saddle prosthesis
comprises 3 criteria (meeting the oncologic goal of
surgery, function, and requirements for analgesia).
It grades overall results as excellent, good, fair, and
poor.5
RESULTS
Perioperative data
The perioperative data are presented in Table 1.
Patients 14, 15, and 16 received radiotherapy prior to
limb salvage surgery, whereas patients 13, 14, and 15
received transcutaneous arterial embolisation.
Acetabular resection was performed on patients 1
to 12 with bone sarcoma and patient 13 with renal
cell carcinoma metastasis; acetabular intralesional
excision was performed on patients 14 to 16. Six
patients had P123 (ilium, periacetabulum, and pubic
rami) resected, 4 had P23 (periacetabulum and pubic
rami) resected, and 3 had P2 (periacetabulum) resected.
Patient 12 with a buttock fibrosarcoma underwent a
2-stage procedure. Wide resection of the tumour of
the involved proximal femur and reconstruction with
a free latissimus dorsi myocutaneous flap were
performed at the first stage. The bone defect was
temporarily reconstructed with a cement spacer prior
to free vascularised myocutaneous flap closure.
Because of the prolonged operation time and high risk
of deep infection at the initial surgery, a saddle
prosthesis was implanted in a second stage 7 months
later. The resection margins of the 12 sarcomas were
Vol. 14 No. 2, August 2006
wide in 10 patients, marginal in one, and intralesional
in one. The resection margins of the 4 metastatic cases
were intralesional.
Reconstruction using the saddle prosthesis was
performed in all 16 patients (Fig. 1). The mean length
of the saddle components was 92 mm (range, 60–
160 mm). In patients 1, 6, and 8 to 11, after resection of
the proximal femur at the level below the lesser
trochanter, a diaphyseal extension of the prosthesis
was used together with the saddle prosthesis. The
mean length of the diaphyseal extension (for 5 patients)
was 95 mm (range, 65–140 mm). A femoral allograft
(60 mm) was used in patient 10. Hip abductors were
preserved or reattached using wires or thick synthetic
suture material in all except patients 6 and 12 in whom
the hip abductors were sacrificed to achieve a wide
margin. With the exception of patients 5 and 6, they
all had Dacron ties around the new joints between the
ilium and the saddle prosthesis for stability. For
patients 1, 2, and 7 who underwent type-P123
resection, the remnant narrow iliac wing was
reinforced with a reconstruction plate over the iliac
crest to prevent postoperative iliac fracture (Figs. 2
and 3).
In patients undergoing saddle prosthesis
arthroplasty following resection or intralesional
excision of the acetabulum, the mean operation times
were 391 (range, 300–490) minutes and 162 (range, 95–
240) minutes, respectively, whereas the mean numbers
of units of blood transfused were 13 (range, 5–26) and
6 (range, 6–6), respectively.
Postoperatively, patients were encouraged to
ambulate with a hip abductor brace and a pick-up
frame as soon as tolerated. The brace was used for
about 3 months, with gradual increase in weight
bearing until full weight bearing was achieved.
Pelvic reconstruction using saddle prosthesis 157
metastases at 12 months and died of the disease at 14
months. Patient 12 developed a fibrosarcoma in the
subcutaneous tissue of the buttock at approximately
18 months. She was alive with no evidence of disease
after removal of the fibrosarcoma.
Functional results
All patients, except patient 10 who remained in
hospital until death, were discharged from the hospital
once they were able to ambulate with crutches or a
pick-up frame. The mean time to ambulation was 7
days (range, 4–10 days) for patients undergoing
acetabular resection and 4 days (range, 1–5 days) for
patients undergoing acetabular intralesional excision.
Patients 2, 3, 5, 7, 11, 12, 14, and 16 were alive and
underwent a functional assessment at 29, 37, 85, 12,
16, 21, 21, and 12 months, respectively. Patient 5 had
the saddle prosthesis removed and replaced with a flail
leg due to a deep infection 6 years after surgery.
In patients undergoing saddle prosthesis
arthroplasty following resection or intralesional
excision of the acetabulum, corresponding mean
MSTS-ISOLS scores were 16 (5+2+3+1+3+2 for pain,
function, emotional acceptance, supports, walking,
and gait; 53%) and 9 (3+1+3+0+1+1; 30%), whereas
corresponding mean TESS scores were 64% and 42%.
The MSTS-ISOLS score of patient 5 with a flail leg was
6 (3+1+1+1+0+0; 20%), whereas the score of patient 16
was 7 (23%) due to her depressive mental state. The
TESS score of patient 5 with a flail leg was 56%.
The score according to the system by Aboulafia
et al.5 was good in patients 2, 3, 7, 11 and 12; fair in
patients 14 and 16; and poor in patient 5 with a flail
leg and severe limb shortening.
Complications
Oncologic results
Of the 12 patients with sarcoma, patients 2, 3, 5, 7, and
12 were alive without evidence of recurrence at a mean
follow-up of 37 months (range, 12–85 months). Patient
11 developed pulmonary metastases at 12 months and
was alive at 16 months. Patients 4, 6, and 9 died of the
disease at 12, 40, and 14 months, respectively. Patients
1 and 8 died of cardiac disease at 4 and 3 months,
respectively. Patient 10 died of sepsis at one month.
Of the 4 patients with acetabular metastasis, patients
14 and 16 were alive at 21 and 12 months, respectively,
whereas patients 13 and 15 died of the disease at 13
and 2 months, respectively.
Two patients had local recurrence: patient 9 had a
large spindle cell sarcoma in the pelvic cavity and
buttock at 5 months. She developed pulmonary
Five patients had serious complications
postoperatively; deep infection (patients 5, 9, and 10),
dislocation (patients 5, 6, and 8), peripheral nerve
palsy (patients 5 and 8), extensive upward migration
of the prosthesis (patient 5), prosthesis dissociation
(patient 9), and haematoma (patient 5).
Patient 5 had both deep infection and dislocation.
She underwent P23H1A resection for a low-grade
osteosarcoma and 2 years later, open reduction for
dislocation of the saddle prosthesis due to a fall. She
had evacuation of a haematoma at 4 years and removal
of the saddle prosthesis due to a deep infection at 6
years. Following extensive upward migration of the
prosthesis (Fig. 4) and sciatic nerve palsy, she
eventually had a flail leg. Patient 9 had deep infection
2 weeks following her P23H12A resection for a spindle
Journal of Orthopaedic Surgery
158 Y Kitagawa et al.
Table 1
Data on patients with saddle prosthesis arthroplasty
Patient
Age
Diagnosis
No.
(years)/
sex
Tumour site
Enneking
stage9
Resection
(Enneking
classification10)
Resection
margin
Adjuvant
Saddle
therapy* base length/
femoral
components
(mm)
Chondrosarcoma Ilium, ischium,
periacetabulum
Chondrosarcoma Ilium, periacetabulum
IB
P123H12A
Intralesional
-
130/140
IB
P123H1A
Wide
-
160/-
Chondrosarcoma
(grade 3)
Chondrosarcoma
(dedifferentiated)
Osteosarcoma
(low grade)
Periacetabulum
IIB
P23H1A
Wide
-
80/-
Periacetabulum,
pubis
Periacetabulum,
pubis
IIB
P123H1A
Wide
-
100/-
IB
P23H1A
Wide
-
60/ -
1
66/F
2
72/F
3
58/F
4
69/F
5
50/F
6
26/M
Osteosarcoma
Proximal femur
IIB
P2H12B
Wide
C
60/65
7
45/F
Osteosarcoma
Ilium, periacetabulum
IIB
P123H1A
Wide
C
130/-
8
61/M
Osteosarcoma
IIB
P123H12A
Wide
-
70/140
9
64/F
IIB
P23H12A
Marginal
-
80/65
10
70/F
P123H12A
Wide
-
55/F
Ilium, pubis,
periacetabulum
Proximal femur
IIB
11
IIB
P2H12A
Wide
C
130/60
(allograft)
100/65
12
64/F
Spindle cell
sarcoma
Malignant fibrous
histiocytoma
Malignant fibrous
histiocytoma
Fibrosarcoma
(soft tissue)
Periacetabulum,
pubis, ischium
Ischium
Buttock
IIB
P2H12B
-
90/-
13
65/M
-
P23H1A
T
100/-
14
66/M
Periacetabulum,
pubis
Periacetabulum
Wide
(initial
operation)
Intralesional
-
Intralesional
R, T
60/-
15
71/M
Periacetabulum
-
Intralesional
R, T
60/-
16
66/F
Periacetabulum
-
Intralesional
excision
Intralesional
excision
Intralesional
excision
Intralesional
R
60/-
Metastasis
(kidney)
Metastasis
(kidney)
Metastasis
(prostate)
Metastasis
(uterus)
* C denotes chemotherapy, T transcutaneous arterial embolisation, and R irradiation
†
MSTS-ISOLS Musculoskeletal Tumor Society-International Symposium on Limb Salvage System
‡
TESS Toronto Extremity Salvage Score
§
NA
not applicable
cell sarcoma treated by several washouts and antibiotic
infusions. She developed prosthetic dissociation
between the saddle prosthesis base component and the
femoral component at 3 months as well as a local
recurrence and pulmonary metastasis and died from
her disease at 14 months. Patient 10 had deep infection
following her P123H12A resection for malignant
fibrous histiocytoma and reconstruction using a
composite saddle and allograft prosthesis in the
femoral defect. She died of sepsis at one month.
Patient 8 had an open reduction for dislocation
at 2 weeks following a P123H12A resection for
osteosarcoma. He had a common peroneal nerve
palsy and died from an acute myocardial infarction
at 3 months. Eight months after a P2H12B resection
for osteosarcoma, patient 6 had a dislocation that was
not reduced. He was treated with a 17-mm heal raiser
and a single cane. This provided good mobility without
pain or obvious limping. He died of pulmonary
metastases at 40 months.
DISCUSSION
In this study, saddle prosthesis arthroplasty for the
management of periacetabular malignant tumour
Vol. 14 No. 2, August 2006
Plating Operation Transfusion
over
time
(unit)
the iliac (minutes)
crest
Yes
490
9
Yes
300
7
No
450
7
No
300
5
No
360
11
No
300
6
Yes
360
10
No
360
23
No
420
19
No
480
18
No
NA
NA
No
190
2
No
480
26
No
95
6
No
150
6
No
240
6
Pelvic reconstruction using saddle prosthesis 159
Follow-up
(months)
Time to
MSTS-ISOLS† TESS‡ (%) Scoring Complications
ambulation
(%)
system by
(days)
Aboulafia
et al.5
Died of heart
disease (4)
No evidence of
disease (29)
No evidence of
disease (37)
Died of
disease (12)
No evidence of
disease (85)
7
NA§
NA
NA
None
7
53
64
Good
None
8
57
61
Good
None
4
NA
NA
NA
None
5
20
56
Poor
Died of
disease (40)
No evidence of
disease (12)
Died of heart
disease (3)
Recurrence then
died (14)
Died of sepsis (I)
4
NA
NA
NA
Sciatic nerve palsy,
dislocation, haematoma,
upward migration, deep
infection, flail leg
Dislocation
5
57
64
Good
10
NA
NA
NA
7
NA
NA
NA
NA
NA
NA
NA
NA
47
72
Good
None
6
50
61
Good
None
8
NA
NA
NA
None
1
30
NA
Fair
None
5
NA
NA
NA
None
5
23
42
Fair
None
Alive with
disease (16)
No evidence of
disease after
recurrence (21)
Died of
disease (13)
Alive with
disease (21)
Died of
disease (2)
No evidence of
disease (12)
enabled moderately good function, but was associated
with a relatively high rate of complications. The
operation time was short and recovery was rapid
with early ambulation. Postoperative function of the
patients was not superior to other reconstruction
procedures based on the score of MSTS-ISOLS (Table
2). The mean functional score has been reported to be
15 to 17 points in saddle prosthesis arthroplasty,7,8 18
to 21 points in pelvic prosthesis arthroplasty,13,14 17 to
20 points in allograft reconstruction (with or without
a total hip prosthesis),15,16 21 points in iliofemoral
a r t h ro d e s i s , 1 7 a n d 8 p o i n t s i n i l i o f e m o r a l
pseudarthrosis.17
None
Peroneal nerve palsy,
dislocation
Deep infection,
prosthetic dissociation
Deep infection
Variations in MSTS-ISOLS scores among different
arthroplasties may be related to support and emotional
acceptance factors. The scores for patients with saddle
prosthesis arthroplasty were higher for pain, but lower
for support, function, and gait categories.8 The scores
for the patients with pelvic prosthesis arthroplasty
were higher for pain and emotional acceptance, but
lower for function and gait categories.13,14 The scores
for patients with allograft reconstruction were
higher for pain and emotional acceptance, lower for
support, function and gait categories.15 These results
suggest that pelvic prosthesis arthroplasty may be
superior to other joint reconstructions in terms of
Journal of Orthopaedic Surgery
160 Y Kitagawa et al.
Figure 1 Patient 3: radiograph of a 58-year-old woman with
pelvic chondrosarcoma showing a saddle prosthesis following
resection of the periacetabulum, pubic rami, and ischium.
Figure 2 T h e t e c h n i q u e o f r e i n f o r c e m e n t u s i n g
reconstruction plate and screws for narrow remnant iliac wing
following resection of periacetabular tumours.
Figure 3 P a t i e n t 2 :
radiograph of a 72-year-old
woman with pelvic
chondrosarcoma taken 21
months after the saddle
prosthesis arthroplasty.
The prosthesis has migrated
up to the reconstruction
plate that reinforces the
narrow remnant iliac wing.
Reactive bony sclerosis
around the prosthesis is
found.
support. Windhager et al. 18 speculated that the
somewhat inferior functional results of saddle
prosthesis arthroplasty could be due to the eccentric
position of the new hip centre that allows only a
limited range of motion. Although arthrodesis results
in immobility of the hip joint and severe shortening of
the lower limb, it achieves a relatively high MSTSISOLS score.
Postoperative function in saddle prosthesis
patients undergoing acetabular intralesional excision
was not superior to acetabular resection, despite
removing less bone and soft tissue. It has been
suggested that the scores reflect underlying disease
Figure 4 Patient 5: radiograph of a 50-year-old woman with
pelvic low-grade osteosarcoma taken 42 months after the
saddle prosthesis arthroplasty. Severe upward migration of the
prosthesis is seen.
severity.19 The diminished function may be related to
the enormity of the resection itself and not the
prosthesis.
The rate of major complications in this study was
comparable to that reported following other
reconstructive procedures. The major complication
rate has been reported as 33% to 65% in saddle
prosthesis arthroplasty,5,7,8,20 25% to 60% in pelvic
prosthesis arthroplasty,6,13,18 46% to 90% in allograft
Vol. 14 No. 2, August 2006
Pelvic reconstruction using saddle prosthesis 161
Table 2
Review of the literature on postoperative function
Authors
Renard et al.7
Cottias et al.8
Kitagawa et al. (current study)
Abudu et al.13
Wirbel et al.14
Bell et al.15
Langlais et al.16
Fuchs et al.17
Fuchs et al.17
Reconstruction
No. of patients
MSTS-ISOLS score11 (%)
Saddle prosthesis
Saddle prosthesis
Saddle prosthesis
Pelvic prosthesis arthroplasty
Pelvic prosthesis arthroplasty
Allograft reconstruction
Allograft reconstruction
Iliofemoral arthrodesis
Iliofemoral pseudarthrosis
13
19
15
13
16
13
12
16
16
52*
57†
53†
70†
63†
65†
56†
71†
25†
* At postoperative 6 months
†
Excluded cases of intralesional excision
reconstruction (with or without a total hip
prosthesis),15,16,21 and 14% to 60% (nonunion rate) in
iliofemoral arthrodesis.17,22 The major complications of
saddle prosthesis reconstruction are: infection,
dislocation, and extensive upward migration.5,7,8,20
Infection was the commonest major postoperative
complication in our series, similar to other
reconstructive procedures; infection rates have
been reported as 18% to 33% in saddle prosthesis
arthroplasty, 7,8,20 17% to 26% in pelvic prosthesis
arthroplasty, 13,23 and 8% to 60% in allograft
reconstruction (with or without a total hip
prosthesis). 15,16,21,24 Risk factors for infection
include long operation time, large blood loss,
decreased volume of surrounding muscles, large
dead space, foreign body reaction, skin complications,
chemotherapy, radiotherapy, and infections of
another organ.21 The high risk of complications with
saddle prosthesis has been attributed to the large
dead space filled only partially by the thin
prosthesis.18
The rate of dislocation has been reported to be 0% to
18% in saddle prosthesis arthroplasty,5,7,8,20 11% to 17% in
pelvic prosthesis arthroplasty,13,23 and 15% to 24% in
allograft reconstruction (with or without a total hip
prosthesis).15,16 Nieder et al.4 reported that only 2 (3%) of
76 patients had dislocation of saddle prosthesis following
revision of a failed total hip replacement. Reconstruction
following acetabular resection may be more unstable
because considerably more soft tissue is sacrificed, and
might be overcome by securing the saddle prosthesis to
the ilium using an artificial ligament to improve its
stability.8 In the present study, patients 5 and 6 in whom
Dacron ties were not used had dislocations.
Extensive upward migration of the prosthesis
has been documented in 0% to 7% of cases of saddle
prosthesis arthroplasty.5,7,8,20 This is nevertheless rare
following other types of reconstruction. Most saddle
prostheses stabilise after some migration, only a few
migrate continuously.4 This may be associated with
deep infection.4 Cottias et al.8 reported a patient with
very marked migration of the saddle prosthesis
following irradiation. Renard et al.7 reported a patient
with severe migration and infection. Our patient 5 with
severe migration also had an infection.
In the case of a narrow remnant iliac wing, we
recommend reinforcing it using a plate and screws to
prevent fracture. In patient 2 with the P123 resection,
plate and screws prevented collapse of the iliac wing.
Renard et al.7 described 2 cases of fracture of the ilium
and one case of fracture of the transposed femur among
15 patients with saddle prosthesis arthroplasty for
periacetabular malignancies.
Saddle prosthesis arthroplasty requires a shorter
operation time because of its technical simplicity. The
mean operation time of the procedure when performed
following acetabular resection is 7 to 7.8 hours 5,7;
shorter than for allograft reconstruction (with or
without a total hip prosthesis) which lasts 9.1–9.5
hours.15,21 The mean operation time of saddle prosthesis
arthroplasty for acetabular intralesional excision is 3
hours19; quicker than for the modified Harrington
procedure (5.3 hours).25 The shorter the operation time,
the lower the risk of infection and blood loss.21
Shorter time to ambulation is another advantage
of saddle prosthesis arthroplasty. The mean time to
ambulation has been reported to be 14 to 16 days in
saddle prosthesis arthroplasty,5,7 14 days in pelvic
prosthesis arthroplasty, 13 4 to 6 weeks in allograft
reconstruction,15,16 and several months in arthrodesis.
In the present study, the time to ambulation was 7 days
after acetabular resection and 4 days after acetabular
intralesional excision. This is shorter than previously
reported.5,7,15,16 Shortening of the postoperative time
to ambulation decreases disuse atrophy and increases
the patient’s quality of life.
162 Y Kitagawa et al.
CONCLUSION
Although saddle prosthesis arthroplasty allows
shorter operation time and earlier ambulation,
postoperative function is only moderate and the risk
Journal of Orthopaedic Surgery
of complications is high. We prefer the saddle
prosthesis because it is a quicker and simpler
reconstruction procedure, particularly as other
techniques involve more prolonged operation times
and are associated with a higher risk of complications.
REFERENCES
1. Choong PF. Review article: reconstructive surgery following resection of primary and secondary tumours of the hip. J
Orthop Surg (Hong Kong) 2000;8:83–94.
2. Kunisada T, Choong PF. Major reconstruction for periacetabular metastasis: early complications and outcome following
surgical treatment in 40 hips. Acta Orthop Scand 2000;71:585–90.
3. O’Connor MI. Malignant pelvic tumors: limb-sparing resection and reconstruction. Semin Surg Oncol 1997;13:49–54.
4. Nieder E, Elson RA, Engelbrecht E, Kasselt MR, Keller A, Steinbrink K. The saddle prosthesis for salvage of the destroyed
acetabulum. J Bone Joint Surg Br 1990;72:1014–22.
5. 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;314:203–13.
6. Bruns J, Luessenhop SL, Dahmen G Sr. Internal hemipelvectomy and endoprosthetic pelvic replacement: long-term followup results. Arch Orthop Trauma Surg 1997;116:27–31.
7. Renard AJ, Veth RP, Schreuder HW, Pruszczynski M, Keller A, van Hoesel Q, et al. The saddle prosthesis in pelvic primary
and secondary musculoskeletal tumors: functional results at several postoperative intervals. Arch Orthop Trauma Surg
2000;120:188–94.
8. 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.
9. Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat
Res 1980;153:106–20.
10. Enneking W, Dunham W, Gebhardt M, Malawar M, Pritchard D. A system for the classification of skeletal resections. Chir
Organi Mov 1990;75(1 Suppl):S217–40.
11. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive
procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993;286:241–6.
12. Davis AM, Wright JG, Williams JI, Bombardier C, Griffin A, Bell RS. Development of a measure of physical function for
patients with bone and soft tissue sarcoma. Qual Life Res 1996;5:508–16.
13. 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;79:773–9.
14. Wirbel RJ, Schulte M, Maier B, Mutschler WE. Megaprosthetic replacement of the pelvis: function in 17 cases. Acta Orthop
Scand 1999;70:348–52.
15. 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;79:1663–74.
16. Langlais F, Lambotte JC, Thomazeau H. Long-term results of hemipelvis reconstruction with allografts. Clin Orthop Relat
Res 2001;388:178–86.
17. Fuchs B, O’Connor MI, Kaufman KR, Padgett DJ, Sim FH. Iliofemoral arthrodesis and pseudarthrosis: a long-term functional
outcome evaluation. Clin Orthop Relat Res 2002;397:29–35.
18. 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;331:265–76.
19. Benevenia J, Cyran FP, Biermann JS, Patterson FR, Leeson MC. Treatment of advanced metastatic lesions of the acetabulum
using the saddle prosthesis. Clin Orthop Relat Res 2004;426:23–31.
20. Natarajan MV, Bose JC, Mazhavan V, Rajagopal TS, Selvam K. The saddle prosthesis in periacetabular tumours. Int Orthop
2001;25:107–9.
21. 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;67:333–8.
22. Campanacci M, Capanna R. Pelvic resections: the Rizzoli Institute experience. Orthop Clin North Am 1991;22:65–86.
23. Uchida A, Myoui A, Araki N, Yoshikawa H, Ueda T, Aoki Y. Prosthetic reconstruction for periacetabular malignant tumors.
Clin Orthop Relat Res 1996;326:238–45.
24. Yoshida Y, Osaka S, Mankin HJ. Hemipelvic allograft reconstruction after periacetabular bone tumor resection. J Orthop Sci
2000;5:198–204.
25. Vena VE, Hsu J, Rosier RN, O’Keefe RJ. Pelvic reconstruction for severe periacetabular metastatic disease. Clin Orthop Relat
Res 1999;362:171–80.