Pelvic ring reconstruction had high union rate after iliosacral resection of Ewing sarcoma
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Published results showed pelvic ring reconstruction using double-barreled free vascularized fibular graft and internal fixation after iliosacral resections achieved a high rate of bone union and good functional outcomes in children.
Researchers analyzed demographic data, tumor characteristics, surgical and adjuvant treatments, radiographic and functional outcomes, complication and reoperation rates, and patient survival among 16 children with pelvic Ewing sarcoma who underwent pelvic ring reconstruction using double-barreled free vascularized fibular graft after iliosacral resection. Researchers noted the fibular graft was placed between the supra-acetabular region distally and the remaining ilium or sacrum proximally, while minimal spinal instrumentation provided stability of the remaining pelvis and spinal column.
Results showed 11 patients had type I and five patients had type I+IV resections with a mean follow-up of 49.8 months. Researchers found 14 patients were alive and two patients had died of disease at the time of final follow-up. The mean time for bone union was 9 months, and all patients had evidence of graft hypertrophy at 12 months, according to results. At the time of final follow-up, researchers noted patients had a median Musculoskeletal Tumor Society score of 80%. Overall, results showed seven patients had complications, of whom three required reoperation for deep infection (n=1), hematoma (n=1) and wound dehiscence (n=1). Researchers found disease relapse occurred in three patients in terms of lung metastases; however, no local recurrence was detected.
“The prerequisite for the technique was having enough supra-acetabular bone stock for internal fixation and placement of a fibular graft. Achieving safe margins required careful planning and an extensive surgical procedure, in addition to rigorous patient selection,” the authors wrote. “The children in whom the tumor had a good radiographic response to neoadjuvant chemotherapy were considered to be good candidates for iliosacral resection and pelvic ring reconstruction. Although the complication rate was high, reoperations were performed only occasionally and without the need for a major revision surgical procedure.”
Perspective
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Pelvic sarcomas remain a challenging dilemma to the orthopedic oncologist. Bulent Erol, MD, and colleagues report excellent functional and oncologic outcomes after the use of vascularized fibula with local spinal instrumentation to reconstruct iliosacral defects in pediatric Ewings sarcoma patients. Free vascularized fibular graft provides a live biologic option for pelvic ring reconstruction and can remain viable in the setting of infection, chemotherapy and, particularly important in the setting of Ewing’s sarcoma, radiation. Free vascularized fibular grafts provide pelvic stability and hypertrophy as they heal, thereby providing fixation that strengthens with time and is able to repair itself should complications or fracture occur.
Spinal instrumentation provides rigid fixation. However, this benefit is theoretical, as incidence of nonunion with free vascularized fibular graft is rare and improvements in functional outcome and time to weight-bearing has not been assessed. Its use needs to be evaluated in face of the added time and risk during the procedure.
The Musculoskeletal Tumor Society score assessed the functional outcome; however, it is limited as there is little evidence comparing scores to true objective functional outcome. Activity assessment after healing of the reconstruction would benefit the manuscript.
All in all, Erol and colleagues present another reconstructive option for type I hemipelvectomy that is associated with strong functional outcome and little postoperative morbidity.
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