COMPLICATIONS – AND THEIR MANAGEMENT – IN PELVIC

MUSCULOSKELETAL TUMOR SURGERY (EXPECT THE UNEXPECTED)

Harzem ÖZGER, Buğra ALPAN, Mustafa SUNGUR, Levent ERALP

Istanbul University, Istanbul Faculty of Medicine, Department of Orthoapedics and Traumatology

Pelvic musculoskeletal tumor surgery

• complex anatomy

• proximity of tumoral masses to • vital neurovascular structures

• gastrointestinal system

• urogenital systems

• morbidity & mortality of complications

• In the literature, aggressive surgical treatment is justified for malignant tumors of the pelvis despite morbidity and mortality.

J Bone Joint Surg Am. 2001 Nov;83-A(11):1630-42.Chondrosarcoma of the pelvis. A review of sixty-four cases.Pring ME, Weber KL, Unni KK, Sim FH.

Clin Orthop Relat Res. 2009 Feb;467(2):510-8. Epub 2008 Oct 15.Osteosarcoma of the pelvis: outcome analysis of surgical treatment.Fuchs B, Hoekzema N, Larson DR, Inwards CY, Sim FH.

Cancer. 1999 Feb 15;85(4):869-77.Pelvic Ewing sarcoma: a retrospective analysis of 241 cases.Hoffmann C, Ahrens S, Dunst J, Hillmann A, Winkelmann W, Craft A, Göbel U, Rübe C, Voute PA, Harms D, Jürgens H

• Reports on complications are very limited

• Infection, LLD, hematoma, skin problems were listed as complications in one patient series.

• Using autografts instead of allografts were advised because of lower incidence of complications

Arch Orthop Trauma Surg. 2003 Sep;123(7):340-4. Epub 2003 Jun 28.Tumors of the pelvis: complications after reconstructionHillman A, Hoffmann C, Gosheger G, Rödl R, Winkelmann W, Ozaki T

Evaluation of complications

“problem-obstacle-sequela” approach originally devised for limb lengthening complications

adapted to complications of pelvic tumor surgery

Problem : conservative management

Obstacle : requiring surgical intervention

Sequela : permanent disability

Patients and Methods

• 1988-2009

• 89 patients

• mean age: 33.7 (2-74)

• primary malignant & local aggressive lesions of pelvis

• 4 died periop due to extensive blood loss

• 7 lost to follow-up

• 8 excluded due to insufficient data.

• Mean follow-up: 29.4 months (1 – 216) for remaining pts.

What do we expect? Predictable: Complications caused by planned

sacrification of certain anatomical parts (sacral roots, sciatic nerve, femoral nerve, hip joint) and caused by extensive surgical exposure and dead space

wound problems (24)

gait difficulty (21)

urinary incontinence (9)

leg length discrepancy (9)

deep infection (8)

paralysis of

lower extremities (7)

anal incontinence (5)

What is not expected? Unpredictable: Theoretically recognized complications not

predicted for that particular case ( iatrogenic injury, failure to complete full resection / recon-struction due to anesthesia-related complications, late / secondary complications )

intraoperative hemorrhagic shock (8)

iatrogenic injuries of urinary system (4) and rectum (1)

inadequate lumbopelvic stabilization (3)

neuropathic pain (3)

hydronephrosis and urinary leakage (1)

meningitis secondary to CSF leakage (1)

abdominal hernia (1)

mechanical ileus (intest. adhesions) (1)

ResultsPts included : 70

Pts with complication : 49 (70.0 %)

Total no. of complications : 106

Complications / pt : 1.5

Predictable complications : 83 (78.3 %)

Unpredictable complications : 23 (21.7%)

Surgical interventions for compl : 25 (23.6%)

Surgical intervention for compl/pt : 0.36

Complication Managementwound problems deep infections(CNS infection)

occasionally

Problem- broad-spectrum

IV antibiotics- VAC

Obstacle- local surgical debridement- local flaps, STSG- colostomy to reduce wound

contamination, for rectal fistula

- (cranial drainage cath. for meningitis)

mostly

- 67 y/o M - pleomorphic sarcoma of right iliac wing.- WR + Sacroacetabular fixation - wound problem + deep infection postop third week- VAC and STSG

- 69 y/old M - recur. sacral chordoma.- extensive wound problems - Myofasciocutaneous flaps

neurologic deficitneuropathic pain

mostlyoccasionally

Sequela (permanent deficit)- Bracing & physiotherapy for lower extremity-Intermittent urinary catheterization for incontinence

Obstacle(muscle transfer ?)

Problem(transient deficit)- Oral gabapentin for neuropathic pain- Bracing &Physiotherapy- Urinary catheterization

Complication Management

- 20 y/o F - GCT of sacrum- Neurogenic bladder at postop 4 wks.- Urinary catheterization

limb length discrepancylimping

mostly

Sequela - Shoe elevation- Orthoses- Physiotherapy for hip ROM

and strengthening of gluteal muscles

Obstacle- Limb lengthening with EF

Complication Management

- 54 y/old M with CS of acetabulum.- Gait difficulty accepted as sequela- Managed with two crutches, bracing and physiotherapy.

- 24 y/o F - chondroblastoma of acetabulum - at postop 9 yrs- LLD was an obstacle, lengtheningwas performed.- Hip abductor weakness sequela

Postop + 1 y

- 19 y/o F - RT for pelvic EWS at 6 y- Pelvic asymmetry causingLLD

SEQUELAor

OBSTACLE ??

1 year later lengthening and consolidation complete

Ureter / bladder / urethra injuries

Complication Management

Problem- Urethral urinary catheterization for urethral injury

Obstacle- Intraoperative repair of ureter,

bladder, prostate- Cystostomy for urethral injuries- Nephrostomy for hydronephrosis

due to ureteral injury

Often multiple problems need to be addressed simultaneously

Complication Management

- 18 y/o M - OS of sacrum + L5- Extensive wound problem, deep infection, ureteral injury and hydronephrosis - Intraoperative abundant bleeding compromised lumbopelvic fixation- Bilateral nephrostomy - Repeat debridements - VAC- Sciatic nerve sacrification

- 16 y/o F - osteosarcoma of right hemipelvis- Internal hemipelvectomy + hip transposition- early wound problem was treated- sciatic nerve sacrification combined with gluteal weakness caused dropfoot and gait difficulty. Accepted as sequela. - Walker + AFO

Preventive measures:

• local flaps and silicon implants as spacers (10)

• colostomy (9)

• preoperative embolisation (7)

• pig-tail ureteral catheterisation (3).

Complication Management

Pre-embolization

Post-embolization

- 30 y/o F- Sacral chordoma

- postop 8 months- permanent

colostomy

- 17 y/o M with OS of right hemipelvis- double J-catheterization preop to avoid ureter injury – successful- neuropathic pain due to femoral head pressing on lumbosacral plexus – oral gabapentin

Conclusion• Multi-disciplinary approach pre-, intra- and

postoperatively to reduce predictable and unpredictable complications.

• Pelvic tumor surgery has high morbidity and mortality. However, if not treated, malignant and local aggressive pelvic tumors cause sequela and eventually death. Therefore it is favorable for the surgeon to manage complications of surgery at problem or obstacle level.

Thank you for your attention…