Annals of Medicine and Surgery 70 (2021) 102812

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Annals of Medicine and Surgery

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Case Report

Partial replacement of pelvis with the hip joint in osteosarcoma treatment:

A case report
Dung Tran Trung, MD., PhD, Professor a, b, *, Sang Nguyen Tran Quang a, b, Hieu Pham Trung a, b,
Nam Vu Tu a, b, Nang Vo Sy Quyen a, Thanh Tran Duc a, Nguyen Tien Dung c, Tran Thiet Son c,
Pham Thi Viet Dung c, Nguyen Van Truong c
a
Department of Orthopaedic Surgery, CHS, VinUniversity, Hanoi, Viet Nam
b
Orthopaedic and Sports Medicine Center, Vinmec Healthcare System, Hanoi, Viet Nam
c
Hanoi Medical University, Hanoi, Viet Nam

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: and importance: Pelvic osteosarcoma is quite rare and is a challenging task for orthopedic surgeons.
Osteosarcoma This aim of this study is to present the first case report using customized 3D-printed prosthesis in Vietnam.
Bone tumor Case presentation: 57-year-old male was diagnosed with pelvic osteosarcoma. After neoadjuvant chemotherapy,
3D printed
we did limb-salvage surgery after partial pelvic resection. He had to undergo another surgery due to an infection
Pelvic replacement
complication that exposed part of the prosthesis. At 6 months follow-up, the patient’s overall status was stable.
Case report
VAS score when moving is 2/10. He can walk with one crutch. Patient is still being followed up and treated.
Clinincal discussion: Management of pelvic osteosarcoma remains a challenging task for orthopedic surgeons.
Advancements in customized 3D-printed prosthesis have been applied in treatment of pelvic osteosarcoma.
Despite the complications, the results are promising. We believe that this is a new and innovative route in surgery
of pelvic osteosarcoma.
Conclusion: Using customized 3D-printed prosthesis is a good way for management of pelvic osteosarcoma.

1. Introduction classification, common techniques of reconstruction are allograft pros­

thesis composites reconstruction, allograft bone graft, saddle hip pros­
Osteosarcoma of the pelvis accounts for 4–10% of all bone cancers thesis or hip arthrodesis, nonetheless complication rates are relatively
and it is a highly malignant tumor. The percentage of lesions located in high. For that reason, novel techniques are still in development, one of
the ilium, the periacetabular area and the sacroiliac joint are 37%, 23%, the promising approaches is 3D printing for custom made prosthetics
and 21%, respectively. The others can be seen in the ischium, sacrum that has brought some optimistic results.
and pubis. The disease is more common in the below 25-year-old and In this report, we present a case of pelvic reconstruction with a
above 50-year-old groups [1]. custom made 3D-printed prosthesis including a part of the ilium and hip
The most effective treatment of pelvic osteosarcoma is a combination joint. This is the first megaprosthesis replacement of the pelvis in Viet­
of chemotherapy and wide resection of the tumor [3]. The overall 5-year nam. This case report has been reported is compliant with the SCARE
survival rate of osteosarcoma is 70–80%, however, according to Fuchs Guidelines 2020 [21].
et al. (2008), pelvic osteosarcoma has a 5-year survival rate of only 38%
[2].
Post-operative reconstruction of hip defect has been discussed for a
long time, mostly applied to type II tumor in Enneking and Dunham

* Corresponding author. Corresponding author. Orthopaedic and Sports Medicine Center, Vinmec Healthcare System, 458 Minh Khai street, Hanoi,Vietnam.
E-mail addresses: [email protected] (D. Tran Trung), [email protected] (S.N.T. Quang), [email protected] (H.P. Trung), drtunam@hmu.
edu.vn (N.V. Tu), [email protected] (N.V. Sy Quyen), [email protected] (T.T. Duc), [email protected] (N.T. Dung), [email protected]
(T.T. Son), [email protected] (P.T. Viet Dung), [email protected] (N. Van Truong).
URL: http://www.dungbacsy.com (D. Tran Trung).

https://doi.org/10.1016/j.amsu.2021.102812
Received 16 August 2021; Received in revised form 3 September 2021; Accepted 3 September 2021
Available online 8 September 2021
2049-0801/© 2021 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D. Tran Trung et al. Annals of Medicine and Surgery 70 (2021) 102812

2. Case presentation

2.1. Case description

Patient was a 57-year-old male, chief complaint of a left hip pain that
had persisted for 9 months. Patient was biopsied and diagnosed with left
pelvic osteosarcoma in a National Cancer Hospital. He was then given 4
cycles of neoadjuvant chemotherapy with IPE regimen: ifosfamide,
cisplatin, epirubicin. Post neoadjuvant therapy outcomes were positive:
pain was reduced, hip ROM was increased and MRI showed a tumor
reduced in size.
Patient had normal weight status (H:1.75 m, W:58Kg, BMI: 18,9Kg/
m2). Clinical examination: there was no sign of systemic or local infec­
tion, patient was mild anemic, palpation showed a mid swollen, soft,
immobile mass in the left ilium area, impinged hip movement. There
were signs of femoral nerve compression, 3/5 quadriceps muscle
strength, numbness on the anterolateral part of the thigh, normal hip
passive ROM. Harris score was 27 which means poor hip function, pa­
tient was in wheelchair full time, his quality of life was affected signif­
icantly. Xray revealed an extensive destructive osteolytic in type 2 pelvic
resection according to Enneking and Dunham (Fig. 1). Fig. 2. Pre - operation in CT 3D (mass 6 × 4x2cm in the left iliac wing, broke
CT and MRI results showed a 6 × 4x2cm tumor on patient’s left the shell and invaded the surrounding muscle mass. There is an increase in
ilium, sign of cortical destruction and muscles spread, angiogenesis in angiogenesis in the center of the tumor. Tumor partially invades into the
the center of the tumor, tumor had invaded part of the acetabular roof acetabular roof).
but not the femoral epiphysis and metaphysis. Further inspection on
other organs showed no signs of metastasis (Fig. 2). (to facilitate dissection to the hip joint and the ilioischial ramus).
In tumor dissection phase, we dissected and exposed the tumor on
the left iliac, overall assessment found a 8 × 6x4cm tumor which had
2.2. Surgical planning and procedure invaded the roof of the acetabulum and groups of muscle attached to the
pelvis (iliopsoas muscle, gluteus medius and gluteus minimus). After
Using Radiant DICOM viewer (Medixant, Poland) from the patient’s that, we continued dissecting the lateral part of the ilium, then the
CT database, we planned the resection area of the tumor and acetabular gluteus muscles were cut and coagulated 3cm from the tumor. We
positioning includes: acetabular diameter, inclination, anteversion, dissected and exposed the greater sciatic notch to identify and preserve
planned stem size and other variants. All data was sent to Chunli Zenda the sciatic nerve, then we continued to the medial part of the iliac to
(Shanghai) for designing and manufacturing the custom-made 3D expose and preserve the femoral neurovascular bundle. All of the iliacus
printed implant. From that design, we can plan the resection margins was excised, and since the lateral femoral cutaneous nerve could not be
including the iliac crest (without the iliosacral joint); iliopubis ramus separated from the tumor, it was resected as well.
and ilioischial ramus margins (Fig. 3). In the stem placement phase, we performed a T-shaped capsulotomy
Patient was given general anesthesia and placed in a 45-degree left to access the hip joint; the femoral neck was cut 1,5cm from the femoral
decubitus position and was secured to the operating table with back saddle at 45-degree angle. Thorough inspection of the resected neck-
pads and girdle. We sanitized and prepped the patient’s two legs and up head block found no sign of cancer invasion. The femoral canal was
to the xiphoid process. The chosen approach was the Mercedes Benz prepared and number 4 stem was inserted, we used Latitude cementless
incision that combined the Smith-Petersen approach (to facilitate prosthesis from Meril (India).
dissection to the ilium and the lesser pelvis) and Watson-Jones approach

Fig. 1. Pre-op pelvis in X Ray and CT.

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D. Tran Trung et al. Annals of Medicine and Surgery 70 (2021) 102812

Fig. 3. Planning resection area.

In tumor and pelvic resection phase, tumor and the affected pelvis (3
resection sites included the ilium, ischium and pubis) and surrounding
tissue (gluteus medius and minimus, iliacus muscles) were resected en-
bloc (Fig. 4). Custom made 3D printed saw guides were fixed to the
resected margins on the pelvis and an oscillating saw was used to cut
through bone. Frozen section of the resection margins was negative
(Fig. 5).
In the implant placement phase, the implant was designed and
manufactured to fit in the pelvic defect, it was 3D-printed using titanium
alloy with a rough surface, all the bone contact surfaces and the ace­
tabulum were smooth with mounts and screw holes (Fig. 6). The
acetabular size was 52mm, inclination and anteversion were 48◦ and
20◦ . Implant was secured to iliopubis ramus with a 4 holes mounting
plate and to the ilioischial ramus and ilium with acetabular screws. A
52/32mm PE liner was placed, we used a 32mm offset +0 ceramic head, Fig. 5. Implant trial and 3D model with saw guides.
the hip joint was reduced and checked in all positions for stability and
ROM. After that, the surgery field was irrigated carefully, two 400ml
negative pressure drainages were placed. The joint capsule was sutured,
the resected muscles was reattached with fiber wire suture to bone. The
wound was closed anatomically.
Total surgery time was 380 mins, total blood loss was 1400ml. We
had transfused 700ml of RBCs intraoperatively, post-operatively, and
the patient was transfused with another 700ml of RBCs. There was no
surgeon-induced fracture, the patient had normal anesthesia recovery
and could move the left leg slightly.

2.3. Postoperation

At 24 hours post-op, the patient could sit up on bed. After 48 hours,

he could walk with a support frame without weight-bearing on left leg
(Fig. 7). Sign of femoral skin numbness had improved, however, he still
Fig. 6. Implant design.

had sensory loss at the innervation site of the lateral femoral cutaneous
nerve. There was no sign of sciatic nerve injury.
During the first 2 weeks, he started practicing muscle-strengthening
exercise as range of motion in bed, and learned to walk with a support
frame for 50 m each day (Fig. 7) [14]. He was discharged at day 10
without any complications of hemorrhage, infection, thrombus or frac­
ture. VAS score at time of discharge was 4/10, active ROM: flex/extend:
70/0◦ , abduction: 10◦ , external rotation: 10◦ , quadriceps femoris muscle
strength was 4/5, Harris hip score was 60 representing poor hip func­
tion. Post-op Xray result: because the implant could not be fitted prop­
erly so the acetabular inclination, anteversion and leg length were
affected. Acetabular inclination and anteversion were 36◦ and 17◦ , legs
length difference was 1cm (Fig. 8).
Post-operative biopsy results showed more than 90% tumor necrosis,
therefore the patient was indicated to continue the IPE neoadjuvant
Fig. 4. Resected tumor with 3D model and implant.

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D. Tran Trung et al. Annals of Medicine and Surgery 70 (2021) 102812

10◦ . He was satisfied with this result. Patient is still being followed up
and treated.

3. Discussion

Osteosarcoma is the most common type of bone cancers nevertheless

its incidence is much lower than other types of cancer in general. In the
pelvis, osteosarcoma is the second most common cancer after chon­
drosarcoma. According to Meyers PA, pelvic osteosarcoma accounted
for 10% of all osteosarcoma [4]. The disease is frequently seen in below
25 and above 55 groups, our patient was in the latter.
We approached the patient with multimodality therapy including
chemotherapy and surgery, in line with Ozaki T (2003)’s plan [1]. Wide
resection with negative margin is crucial in pelvic osteosarcoma and it
depends on many factors such as: tumor size, metastasis, post neo­
adjuvant response of the tumor [5]. Type II tumor resection is one of the
most challenging procedures in the pelvic area because of the multidi­
mensional structures, numerous surrounding vessels and nerves in a
tight and deep space. Post op outcomes were still poor [6]. Our patient
required a type I + II + III resection followed by reconstruction with a
custom-made 3D printed implant, this is a novel technique in managing
this type of cancer which ameliorates a patient’s quality of life as well as
physical and mental wellness [7,8].
According to Wang, indications for surgery were: (1) confirmed
malignant or invasive pelvic tumor without metastasis beyond control,
(2) good response to neoadjuvant chemotherapy, (3) favorable surgical
margin under limb salvage, and (4) no obvious invasion of the iliac
Fig. 7. (Day 2 post-operative the patient learned to walk with a support frame).

regimen for 3 more cycles. After 1 cycle chemotherapy after surgery, his
white blood cells were lower lead to incision infection at the super
lateral iliac crest then progressed to partial implant exposure. Manage­
ment was divided into 2 phases: first, the patient was admitted for
emergency surgery, we debrided thoroughly and placed a VAC, wound
fluid was sent for microbial culture and antibiotic sensitivity testing, and
the patient was prescribed with a combination of Ceftazidime and
Gentamicin. Next, the defect was reconstructed with a pedicled tensor
fasciae latae flap combined with vastus lateralis musculocutaneous flap
one week later (Fig. 9). The flap healed well and the patient was dis­
charged the following week.
At 6 months follow-up, the patient’s overall status was stable, inci­
sion healed completely (Fig. 10). VAS score when moving is 2/10. He
can walk with one crutch. Active ROM: flexion/extension: 90/0◦ , Fig. 9. Tensor fasciae latae flap combined with vastus lateralis musculocuta­
abduction: 15◦ , adduction: 10◦ , external rotation: 20◦ , internal rotation: neous flap.

Fig. 8. Postoperative X Ray and CT 3D.

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D. Tran Trung et al. Annals of Medicine and Surgery 70 (2021) 102812

implant is 1 month, sometimes, it is too long for a patient to wait.

We used the incision combined Smith – Petersen and Watson – Jones
approaches (Mercedes or T-shaped incision). The gluteus muscles on the
outside and the pelvic muscles on the inside were dissected and released
3–5cm from the tumor. The sciatic nerve and femoral neurovascular
bundle were exposed and preserved. However, we could not preserve
the lateral femoral cutaneous nerve that was severed because of its
adhesion to the tumor. According to Lackman, large incision helped
open the surgical field on all four sides, which brought a large field of
view made it easier for dissecting and approaching the tumor as well as
other surrounding structures, moreover, this incision preserve the
perfusion of the femoral artery to the anterior flap and superior gluteal
artery to the posterior flap [12].
As we discussed, the implant did not fit properly, the outer part of the
implant corresponding to the anterior superior iliac spine was pushed
Fig. 10. The incision healed completely. out about 1cm, therefore was only covered by skin and after neo­
adjuvant therapy, the spot got infected and the implant was exposed. It
took two surgeries to completely cover the implant, the first one was to
vessels, sciatic nerve or femoral nerve. Contraindications for surgery
debride and place a VAC on the wound, the second followed next week
includes (1) extensive invasion with poor response to chemotherapy, (2)
to reconstruct the defect with fascia latae and vagus lateralis muscle
nonstandard open biopsy leading to local tumor contamination, and (3)
flap. In his research, Wilson reported a complication rate of 49% and
intolerance to surgical procedures due to poor general condition [9]. We
37% of those needed reoperation [6]. According to Han’s research, the
think that in case of metastasis, surgical indication should be considered
complication rate was 50% mostly related to delayed wound healing and
if a patient’s health status fits surgical and anesthetic conditions because
infection [13].
of remarkable benefits on patients physical and mental health from the
Patient was put on a rehabilitation program early under supervision.
procedure.
First day: he practiced sitting and passive motion on CPM. Second day:
Many techniques have been used in post tumor resection hip
partial-weight-bearing walking with walking frame for 20 m. 3rd − 10th
reconstruction like: Harrington procedure, saddle prosthesis, Allograft
day: practiced muscle strength and improved ROM. Patient was dis­
prosthesis composite, modular hip joint or allograft [17–20], …how­
charged on post-op day 10. Rehab objectives were to facilitate wound
ever, in Brown’s analysis of over 1700 patients, complication rate was
healing with stable stretch across the incision, maintain knee and ankle
up to 50% which is fairly high, most complications were due to infection
ROM as well as avoid stiffness of hip joint. Adele Wingrave emphasized
and prosthesis instability. However, with advancement in 3D printing,
that progressive rehabilitation helped restore normal knee and ankle’s
patient-specific instruments have seen some early positive results [10].
functionsβ as the opposite leg. [15].
3D printing has been used by Kamada since the early 1980s and
At 6 months follow-up, the patient can walk with one crutch, Harris
recently, the technology has been applied in Vietnam which helps sur­
hip score was 72, there was no sign of local recurrence, and the implant
geons practice on real size models prior to the surgeries, make precise
was in the correct position. Our result was similar to Chen’s report:
implants, reduce surgery time, the models also make pre-operation
Harris’ score was 73 at 1 month post op, 79 after 6 months [8]. The
explaining and demonstrating to patients and relatives much more
limitation of our study is the short follow-up period. This is the initial
straightforward.
results of a difficult and complicated surgery that needs more time to get
Evrard showed that incorporating 3D printing in PSI helped reduce
satisfactory results.
local recurrence, R0 resection margin rate was 88%, however mean
operative time was 10 hours [11]. Identifying the correct resection
4. Conclusion
border is one of the main keys in obtaining R0 margin both macro­
scopically and microscopically and also facilitates the implant place­
Partial pelvic replacement with custom-made 3D-printed implant is
ment [16]. Though our 3D printed PSI helped reduce surgery time, the
an effective solution in managing osteosarcoma of the pelvis. This
implant placement was not precise because of soft tissue impingement
method not only helps restore pelvic function but also pelvic anatomy.
and the saw guides did not have grooves so the saw tended to slip
However, this is a complicated procedure with many challenges to
therefore we were unable to create a perpendicular cut on every plane.
overcome such as: risk of neurovascular injury, skin and soft tissue ne­
Our 3D-printed implant design had a rough surface with multi holes
crosis because of inappropriate coverage, delayed wound healing which
for muscle reattachment and according to Peng Wei, this type of struc­
eventually leads to incision infection, impair hip biomechanic. There­
ture also helped with bone ingrown, reduce implant instability, diffuse
fore, this procedure should be performed in a large orthopedic center
pressure on implant and reduce implant’s weight [7]. However, this type
with carefully selected patients to achieve the best outcome.
of structure also makes an adhesive surface for bacteria which brings
higher risk of infection and makes it harder to debride. We had a really
Ethical approval
hard time debriding all of the necrotic infected tissue from the implant in
the reoperation.
The procedures used in this study inhere to the tenets of the Decla­
Although we had meticulously planned and calculated all the
rations of Helsinki.
resection planes, fitting the implant to all 3 planes was still very chal­
lenging because all three sites: iliac crest, iliopubis and ilioischial
resection site must be cut precisely, and this was also the cause of long Sources of funding
surgery time. Since the implant could not fit perfectly, the patient’s hip
inclination, anteversion and leg length was different from pre-op We declare no funding for this study.
calculation. Total surgery time was about 7 hours, amount of blood
loss was 1400ml, lower than other researches 10 [11]. Author contribution
One of the main setbacks of 3D-printed PSI is that the implant is not
available. The average time for designing and manufacturing the Dung Tran Trung: the main doctor conceived the original idea and
operated the patients, revised manuscript.

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