Rev. bras. ortop. vol.52 número6

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Reconstruction

with

iliac

pedestal

cup

and

proximal

femur

tumor

prosthesis

after

wide

resection

of

chondrosarcoma

–

10-year

follow-up

results

夽

Diogo

Lino

Moura

∗

_,

_Rúben

_Fonseca,

_João

_Freitas,

_António

_Figueiredo,

José

Casanova

CentroHospitalareUniversitáriodeCoimbra,DepartamentodeOrtopedia,Coimbra,Portugal

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t

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o

Articlehistory:

Received23September2016

Accepted21November2016

Availableonline30December2016

Keywords:

Boneneoplasms

Chondrosarcoma Pelvis

Reconstruction

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b

s

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Chondrosarcomaisamalignantcartilage-formingneoplasm.Itisdifficulttotreatbecause

ofresistancetobothchemotherapyandradiation,makingwidelocalexcisiontheonly

treat-ment.Thisreportpresentsanactive,43year-oldmanwhowasdiagnosedwithrecurrent

clearcellchondrosarcomaoftheproximalleftfemur,previouslyreconstructedwithatotal

hipprosthesis,extendingtotheweight-bearingdomeoftheacetabulum.Cancerstaging

studyrevealednosignsoftumordisseminationatdistance.Giventheexcellentfunctional

statusofthepatient,theauthorsperformedaEnneking–Dunhamtypeperiacetabularpelvic

resectionandresectedenbloc,withthetotalhipprosthesisincluding22cmofthefemur

andaportionofthehipabductorapparatus.Acetabularreconstructionwasperformedwith

anon-cementedpedestalcupprosthesisfixedattheiliac,andin-femurreconstruction

uti-lizedacementedsilver-coatedproximalfemurmodularprosthesis.Today,aftera10-year

follow-up,thepatientiswalkingwithoutcrutches,hepracticesrecreationalcyclingwithout

assistance,andheisasymptomaticandfreeoftumoraldisease.Atpresent,nosignsof

rel-evantloosening,instability,infection,heterotopicossification,oranyothercomplications

havebeenobserved.Pelvicreconstructionsarechallengingandriskysurgeries;however,the

appearanceofmorefunctionalimplants,likethepedestalcupprosthesis,anditscorrect

applicationandindication,mayallowpromisingclinicalandfunctionalresultswithlow

complicationsrate.

Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

夽

WorkperformedattheCoimbraHospitalandUniversityCenter,OrthopedicsDepartment,Coimbra,Portugal.

∗ _{Corresponding}_author_.

E-mails:dflmoura@gmail.com,dflm12345@gmail.com(D.L.Moura).

http://dx.doi.org/10.1016/j.rboe.2016.11.007

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doaparelhoabdutordoquadril.Areconstruc¸ãoacetabularfoirealizadacomumaprótese

depedestalnãocimentadafixadanoilíacoeareconstruc¸ãonofêmurutilizouumaprótese

modularcimentadaparaofêmurproximalcomrevestimento emprata.Hoje,apósum

seguimentodedezanos,opacienteandasemmuletas,praticaciclismorecreativosem

assistênciaeestáassintomáticoelivrededoenc¸atumoral.Nãoforamobservadossinais

deafrouxamentorelevante,instabilidade,infecc¸ão,ossificac¸ãoheterotópicaouquaisquer

outrascomplicac¸ões.Asreconstruc¸õespélvicassãocirurgiasdifíceisearriscadas;

entre-tanto,osurgimentodeimplantesmaisfuncionais,comoaprótesedepedestal,esuacorreta

aplicac¸ãoeindicac¸ãopodempermitirresultadosclínicosefuncionaispromissores,com

baixataxadecomplicac¸ões.

EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://

creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Chondrosarcomaisacartilageformingmalignneoplasm.It

is the second most common primary malignancy of bone

and is more frequent in males above 40 years old.It can

beprimaryorsecondary,frequentlyoriginatingfrombenign

tumors’malignization.Mostfrequentlocationsincludepelvis,

proximal femur and scapula. Chondrosarcoma is difficult

to treat because it is resistant to both chemotherapy and

radiation, making wide local excision the only effective

treatment.1,2_The_extent_of_the_resection_margins_depends_on

thetumorgradeandlocation.3,4_Local_recurrence_is_frequently

seenafterintralesionalexcision,thuswidelocalexcisionis

sometimesemployeddespitesignificant morbidity, evenin

low-gradelesions.Thesurgeonmustweigh theriskof

sig-nificantmorbidity withthe abilitytominimize the chance

oflocalrecurrenceandmaximizethelikelihoodoflong-term

survival.2_The_most_important_predictors_of_poor_prognostic

forpatientswithchondrosarcomaareahighhistologicalgrade

andageover50yearsold.5,6

Chondrosarcoma,Ewing sarcoma and osteosarcoma are

the most frequentprimitive malignant bone tumor

affect-ing the iliac bone.7 _As _opposed _to _iliac _and _obturator _ring

resections,iliacwingandacetabularresectionsrequire

recon-struction. This is due to the pelvic ring disruption that

affects weight bearing, demanding reconstruction to allow

ambulationandanacceptablefunctionalresult.7

Reconstruc-tion of periacetabular defects after pelvic tumorresection

ranks amongthe most challengingprocedures in

orthope-dicsurgery.7,8_Current_solutions_include_total_hip_replacement

and reconstructionwithsaddle ormodulartumor

prosthe-sis,pedestalcupprosthesis,massiveallograftwithorwithout

prosthesisandfemoro-ilacarthrodesis.7,9_The_choice_is_made

balancing the following items: remaining acetabular bone

stockqualityforprosthesisfixation;generalhealthstatusand

functionallevelofthepatient.9

Case

description

We present the caseofa 43 year-oldactive manthat was

diagnosedwitharecurrentclearcellchondrosarcomaofthe

proximalleft femur,extendingtothe weight-bearingdome

oftheacetabulum.Cancerstagingstudyrevealednosignsof

tumordisseminationtodistance.Thepatientwaspreviously

submitted in other healthcareinstitution to two curettage

resections ofbenignlocal chondrogenictumors(17 and 16

yearsagorespectively)andoneproximalfemurresection

fol-lowed by reconstruction witha modular revision total hip

arthroplastyS-ROM®(12years ago).Thelattersurgerywas

performed already with the diagnosis of chondrosarcoma

(Fig.1).

Giventhe excellentfunctional status ofthe patient and

the localizedtumordisease,wedecided toperform awide

resection and reconstruction.Using ilioinguinal and lateral

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Fig.1–Proximalleftfemurresectionfollowedby reconstructionwithamodularrevisiontotalhip arthroplastyS-ROM®.

resection Enneking–Dunham type II (Fig. 3).10 _In _order _to

achieveclearmarginsthe tumorwasresectedinbloc with

thetotalhipprosthesis,22cmoffemurandaportionofthe

abductorhipapparatus.Thetumorwassurroundingthehip

prosthesisand its macroscopic appearanceis presentedin

Fig. 4. Acetabularreconstruction was performedwith

non-cementedpedestalcupprosthesisfixedattheiliac(Pedestal

Cup Zimmer®) (Fig. 5). In femur reconstruction we used a

cementedsilver coatedfemurproximalmodularMUTARS®

prosthesis(Fig.6).Afterpolyethyleneinsertapplication,

pros-thesisreductionandstabilitytests,atreviratubewasapplied

toensurereconstructionofsofttissueandmuscular

reinser-tions(Fig.7).Inordertoachieveadequateacetabularpedestal

Fig.2–Macroscopicaspectoftherecurrentclearcell chondrosarcomaoftheproximalleftfemur–ilioinguinal andalateralthighapproaches.

Fig.3–PeriacetabularpelvicresectionEnneking–Dunham typeII.

fixationandstability,surgeryresultedina2cmshorteningof

theinferiorlimb,correctedwithacompensatoryshoe.

Results

Postoperative periodwasunremarkable (Fig. 8). Progressive

weightbearingwasstartedaccordingtopaintolerance.The

patient was walking without crutches at3 months

follow-up. After10 years thepatient iswalking withoutcrutches,

only withaslight Trendelenburg sign.He isa recreational

cyclistandheisasymptomaticandtumoraldiseasefree.Until

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Fig.5–Acetabularreconstructionwithanon-cemented pedestalcupprosthesisfixedattheiliac(PedestalCup Zimmer®).

Fig.6–Femurreconstructionwithacementedsilvercoated femurproximalmodularMUTARS®prosthesisand

acetabularandfemurreconstructionfinalaspect.

Fig.7–Treviratubeapplicationtoassurereconstructionof softtissueandmuscularreinsertions.

peakincidenceduringthethirdandfourthdecadesoflife.

Clearcellchondrosarcomaisanepiphysealtumorthatcanbe

confoundedwithlowgradechondrosarcoma.Howeverithasa

relativelyindolentmalignancy:itcanbelocallyaggressiveand

roughly25%ofpatientsexperiencelocalrecurrencesoftheir

tumorsordevelopmetastasis.Howevertumor-relateddeathis

uncommon,particularlywhenthelesionhasbeencompletely

resected“enbloc”.11

In the present case, either due to recurrence or tumor

cells persistence afterprevious resections, the patient was

diagnosedwithasizable chondrosarcoma(8cm lengthand

5cmthickness)ofarareandaggressivetype,inafemurthat

hadaprevioustotalhipprosthesis.Treatmentoptionhadto

bewidetumorresectionwithclearmargins,involvingboth

acetabulumandfemurresectionsduetothetumorextension.

Giventheexcellentgeneralcondition,absenceofsignsof

dis-seminateddiseaseandthehighfunctionallevel(inayoung

patient),acetabularefemurreconstructionwerenecessary.

Periacetabular reconstruction remains a high

techni-cal demanding challenge. Reconstructive techniques are

generallyassociatedwithunsatisfactorymechanicaland

non-mechanical complication rates.8 _{Enneking–Dunham} _type _II

pelvicresectionsareassociatedwithmoremechanical

com-plications than isolated type I and typeIII resections.12–14

There are two main options for periacetabular

recons-tructions that require some remaining iliac bone stock:

saddle prosthesis, with aproximal saddle component that

articulates with the remaining iliac bone; ball-socket type

prosthesiswithapedestalorstem componentfixedatthe

remainingiliac.9_Saddle_prosthesis_were_previously_the

gold-standard forperiacetabular reconstructions, howeversome

studiesfoundtheywereassociatedwithhighratesofmajor

complications, such as infection, prosthesismigration and

dislocation.9,13,15–17_Instead,_despite_of_pedestal_cup_prosthesis

arerecentimplants,theirmoreadvantageousbiomechanicsin

termsofaxialstressdistributionacrossbone–implant

inter-face, allowsthemtobeachieving goodoutcome reportsin

literature.Thisreconstructionisalsocurrentlyconsideredan

easiersurgicaltechnique,takinglesssurgicaltimeand

hav-inglowercomplicationsrateatshorttermcomparingtoother

pelvicreconstructions.8,18

Ourcentercurrentchoiceinperiacetabularreconstructions

isthepedestalcupprosthesisfixedattheiliacanda

modu-larsilvercoatedprosthesisfortheproximalfemur.Silveris

knowntohaveantimicrobialactivityandsilver-coatedtumor

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Fig.8–Postoperativepelvicandfemurradiographs.

lowerrateofearlyperiprostheticinfection.19–21

Acknowledg-ingthehighriskofinfectionofpatientssubmittedtomajor

invasiveresectionsofbonetumorsand reconstructed with

bigdimensiontumorprosthesis,wecurrentlychoosesilver

coatedprosthesisforthistypeofsurgery.

Asthemajorityofpatientsinwhichthesereconstructions

areperformed haveshortlifeexpectancy,current scientific

evidenceaboutsurvivaloftheseimplantsatmediumandlong

termisabsent.Wepresenttherarecaseofapatientsubmitted

to acetabular and proximal femoral arthroplastic

recon-struction and the functional,mechanical and radiographic

resultsat10yearfollow-upperiod.Patientisasymptomatic,

independently ambulating and even practicescycling. Our

team does not recommend sports practice (mainly those

associated with impact activities or an important risk of

falls) following pelvicand femur reconstructions. However

thepatientassumedtotalresponsibilityforhisdecisionand

continues sports activity without any adverse event until

today.Theonlylimitationreferredbythepatientisaslight

Trendelenburgclaudication,probablyduetopartialresection

oftheabductorhipapparatus. Theexcellentresultsofthis

patientmaybeexplainedbythewideandclearmarginsof

tumorresection,therespectforanatomicalstructuresandits

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Fig.9–Full-limbradiographat10yearsfollow-up.

proximal femur prosthesis that had excellent clinical and

functionaloutcomesat10yearsfollow-up,withoutany

com-plicationuntilnow.Pelvicreconstructionsarechallengingand

riskysurgeries.Thedevelopmentofmorefunctionalimplants,

suchasthe pedestalcup prosthesis,its correctapplication

andindications,mayallowpromisingclinicalandfunctional

results,withalowrateofcomplications.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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