| IntroductionAlthough the pelvic tumors is not common, but the harm is very great. Statistically, m alignant bone tumors, about 5% occur in the pelvis. Primary tumors including benign tumor invasive power (such as giant cell tumor of bone) and osteosarcoma, chondrosarcoma, metastatic tumor can be derived from different organs, the more common metastatic tumor lung, breast, thyroid, kidney and prostate. The early clinical manifestations of pelvic tumor was not typical, groin or waist leg pain may be the only symptom, most patients showed persistent and progressive dull pain or pain. Therefore, for chronic groin or waist leg pain patients, in addition to considering the common pathogeny, but also we should consider the pelvic tumor (particularly periacetabular tumor), in order to reduce the misdiagnosis. There are many reasons leading to misdiagnosis or missed diagnosis. Because of pelvic tumors especially acetabular tumor incidence rate is low, the physician rarely meet in the daily clinical work, and the performance of the persistent and progressive dull pain or pain in the symptoms, physicians can easily account for some common diseases.Such as lumbar spinal stenosis, lumbar disc herniation, piriformis syndrome, hip, knee joint degeneration etc.Secondly, the pelvis and the surrounding soft tissue structure is complex, making it difficult to find early bone and soft tissue abnormal locations in radiology, it makes the physical examination difficult. Malignant pelvic tumors not only undermine the integrity of the anatomy of the pelvic ring, resulting in a loss of function, also threaten the life of patients. In particular, acetabular damage is the main problem, the pain of patients is generally heavier, limited function seriously, treatment with reduced weight, the effect is not obvious. In the past, semi pelvic amputation surgery is the main method of treatment, but the semi pelvic amputation caused significant defects in joint function and appearance of the patients after surgery, make patients psychologically difficult to accept. With the further development of the imaging technology and operation technology,and in 1978, Steel for the first time put forward the internal hemipelvectomy, limb salvage has become the main method of treatment of pelvic malignant tumor. Because it is more complex to the pelvis and the surrounding soft tissue anatomy and larger risk in operative resection of the tumor, there are high requirement in reconstruction of pelvic stability and the function of hip joint in technology.Preoperative, the partition of pelvic tumors,which is important to determine the operation resection range and choice of functional reconstruction. And operation excision boundary is directly related to the recurrence rate after surgery.At present, there are many reconstruction method such as tumor bone shell inactivation and replantation, allogeneic semi pelvis transplantation,artificial hemipelvic replacement and the composite reconstruction of Pedicle screw fixation system combined with bone cement in our hospital, which mostly meet the needs of patients functionally and psychologically. Acetabular tumor resection and reconstruction is a very complex technology in the field of Department of orthopedics. Perfect imaging data, preoperative characteristics of tumor,sufficient preoperative preparation, tumor resection completely, suitable prosthesis replacement and reasonable functional training after operation, which is necessary.In recent years, with the development of neoadjuvant chemotherapy and biotherapy,the survival rate of the patients with malignant pelvic tumors can enhance unceasingly, the complications after the reconstruction are reduced, function improved, but 5 years survival rate is still low. At present, treatment of pelvic malignant tumor is not very standardized, and lack unified standard of treatment, some physicians lack experience for pelvic tumor treatment principle and operation indications, especially for tumors of pelvis Ⅱ and Ⅲ regions. Some tumors which is sensitive to chemotherapy, we can use the new adjuvant chemotherapy scheme, Part of the tumor can be performed postoperative radiotherapy, improve survival rate. For some patients with giant cell tumor of bone and metastatic tumor of bone we can use bisphosphonates to prevent recurrence postoperatively.But treatment of acetabular malignant tumor is still facing challenges.ObjectiveTo evaluate the efficacy of two kinds of operation scheme for the treatment of periacetabular tumorMaterials and methods1 Patients and tumor samplesWe retrospectively identified 58 patients with periacetabular tumor occurring between 2003 and 2013 who met the following criteria:(1)integrity of the medical records;(2)first surgical treatment in our department;(3)periacetabular bone destruction;(4)no other Ilium involvement;(5)patients with metastasis of tumor can effectively control the primary lesion;(6)treatment for the purpose of en bloc resection;(7)composite reconstruction of Pedicle screw fixation system combined with bone cement.Among the 58selected patients,there are 32 males and 26 females with an average age of 52.0±13.9 years(range,15-72 years).20 with chondrosarcoma,9 patients were diagnosed with osteosarcoma,6 with giant cell tumor(GCT),5 with Chordomas. 6 with malignant fibrohistiocytoma(MFH),4 with malignant chondroblastoma.8 with metastatic tumors. All patients were treated with operation, and the postoperative pathological diagnosis.2 TreatmentSufficient preoperative preparation, in the 72 hours and 24 hours before the operation, we performed femoral artery embolization method to control blood pressure is used in the process of tumor resection, That is, to keep the patients with mean arterial pressure at around 50mmHg. Using the composite reconstruction of pedicle screw fixation system combined with bone cement (Tianjin Zhengtian medical instrument development Co.Ltd):① Tumor resection, patients take the lateral position after general anesthesia and surgical approaches of "herringbone" from the iliac wing along the inguinal to the ipsilateral symphysis pubis and the greater trochanter.with auxiliary incision when necessary. The incision of skin, subcutaneous tissue, deep fascia layer by layer. It is important that we protect the femoral nerve, femoral artery, vein and spermatic cord in inguinal region. Periosteal raspatory separates bluntly superior ramus of pubis, Oscillating saw cuts off ramus of pubis and ischium. At this time we should pay attention to the protection of the obturator vessels, with ligature when necessary. Stripping lateral muscles of iliac wing, exposing femoral head after incision of hip joint capsule, femoral head is cuting off with Oscillating saw, then removing the femoral head. After exposing ilium, Oscillating saw cut Ilium between the anterior superior iliac spine and the greater sciatic foramen. Pay attention to the protection of superior gluteal artery vein.high ligation, when necessary. Cut off the Ⅲ region of the ramus of ischium and pubis in the obturator, complete removal of tumor. Osteotomy in operation is at least 2-3 cm away from the tumor margin.②Reconstruction of prosthesis, Periacetabular tumor resection and composite reconstruction. First operation scheme (composite reconstruction of acetabulum conbined with pelvic ring):1 piece of spinal screw of 6 mm diameter are placed superior ramus of pubis,2-3 pieces of ilium wing to the sacroiliac joint direction 2.5cm length of the screw tail was set aside, and point to the acetabulum.The connecting bar is fixed on the screw. The tail of each screws contact with the acetabular roof. And set aside space of acetabular cup mixed with vancomycin bone cement. Second operation scheme (simple composite reconstruction of acetabulum):only2 piece- es of spinal screws of 6 mm diameter are placed from ilium wing to the sacroiliac joint direction,and/or inserting 1-2 cancellous screws In order to strengthen the stress of acetabular roof. The connecting bar is fixed on the screw. The tail of each screws contact with the acetabular roof. Acetabular anteversion fixed requirement is 20’-30’, extraversion 40’-50’ to avoid postoperative dislocation. Postoperatively, routine prevention of thrombosis, prevention of infection, wound dressing and supportive treatment.3 Evaluation criteriaThe patient compliations and limb function assessment (MSTS scores) was evaluated three months or six months after operation.That is, whether the pain, limb function and activity, patient satisfaction, bearing, walking ability and gait.4 Statistical analysisAll the data were processed by Spss13.0. All the data were noted in mean±standard deviation (mean±SD); Quantitative data were compared by means of two independent samples T-test. Qualitative data were compared by means of the x2 test.Statistical significance was set at P<0.05.ResultNo patients died during perioperation. First operation scheme:32 patients with periacetabular tumors. The operative time of 32 cases were230.31±34.99 miniutes (190 to 320 miniutes). The intraoperative blood loss of these cases 1970.63±872.97m 1(900 to4100ml). Over 28 patients were followed up. The MSTS were 21.48±1.25 (18.3 to 23.6 scores) In three months after operation. The MSTS were 21.63±1.05 (19.3 to 23.6 scores) In six months after operation. After operation, 7patients appeared controllable complications,the incidence of complications: 21.9%.2 cases of venous thrombosis, urokinase and low molecular heparin were given thrombolytic therapy, without further deterioration.3 patients had delayed healing of incision and healing of incision after dressing.2patinets presented deep infection,by large dose of broad-spectrum antibiotics and bedside incision and debridement and drainage, Incision healed at 30 d and 35d after operation respectively.Second operation scheme:26 patients with periacetabular tumors.The operative time of 26 cases were204.62±37.55 miniutes (160 to 300 miniutes). The intraoperative blood loss of these cases 1509.62±809.30ml(700 to3800ml). Over 23 patients were followed up. The MSTS were 19.70±1.50 (17.4 to 22.5 scores) In three months after operation. The MSTS were 19.93±1.43 (17.5 to 22.5 scores) In six months after operation. After operation,5 patients appeared controllable complications,the incidence of complications:19.2%.1 patient occured sciatic nerve injury, recovered after 3 months.1 case of venous thrombosis, urokinase and low molecular heparin were given thrombolytic therapy, without further deterioration.2 patients had delayed healing of incision and healing of incision after dressing.1 patient presented dislocation of hip joint in 2 weeks after operation.incision reduction and "medullary spica cast" fixed Hip in six weeks. Patients were followed up for 5-6 months, without redislocation.1 case of osteosarcoma,2 cases of chondrosarcoma.2 cases of chordoma,2 cases of giant cell tumor were lost to follow-up. The remaining 51 patients were followed up by telephone or outpatient, followed up for 5 months-10 years.7 cases of osteosarcoma, chondrosarcoma in 12 patients with pulmonary metastasis, were died of respiratory failure, the remaining patients were tumor free survival.4Patients with malignant fibrohistiocytoma(MFH) died in two year after operation.2 cases of local recurrence after surgery respectively for 14 months and 16 months, survived with tumor after hemipelvectomy.2 cases of malignant chondroblastoma occurred local recurrence after operation for more than 1 years, be hemipelvectomy, to the end of follow-up,1 patient survived with tumor,1 cases died of lung metastasis, the remaining two cases survived without tumor. At the last follow-up date, giant cell tumor of bone, chordoma didn’t occurred local recurrence orlung metastasis; patients with metastatic tumor died in three years after operation.The incidence of postoperative complications of first operation scheme and second operation scheme on periacetabular are equal to each other (P=1.00) and there are no difference via being checked by statistical tests.The operative time of used first operation scheme were longer than second operation scheme, there are difference (P=0.009) via being checked by statistical tests.The blood loss of first operation scheme were longer than second operation scheme, there are difference (P=0.044) via being checked by statistical tests.Functional score after operation of used first operation scheme were higher than second operation scheme, there are difference via being checked by statistical tests,3 months after operation (p<0.05),6 months after operation (p<0.05). ConclusionFirst operation scheme and second operation scheme are effective method for treating periacetabulum.Second operation scheme required shorter operative time and less blood loss.but recovery of postoperative function is worse than first operation scheme. |
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