complications – and their management – in pelvic musculoskeletal tumor surgery (expect the...
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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
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
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
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
- 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
- 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.