Abstract
Aims:
Although internal hemipelvectomy is associated with a high incidence of morbidity, especially wound complications, few studies have examined rates of wound complications in these patients or have identified factors associated with these sequelae. The present study aimed to (1) determine the rate of wound and other complications requiring surgery after internal hemipelvectomy, and (2) identify factors that affect the rate of wound complications and can be used to stratify patients.
Materials and Methods:
The medical records of 123 patients undergoing internal hemipelvectomy were retrospectively reviewed, with a focus on overall and wound complications. Logistic regression analyses were performed to examine the association between host, tumor, and surgical factors and rates of postoperative wound complications.
Results:
The overall rate of postoperative complications requiring surgery was 49.6%. Wound complications were observed in 34.1% of patients, hardware-related complications in 13.2%, graft-related complications in 9.1%, and local recurrence in 5.7%. On multivariate analysis, extrapelvic tumor extension (odds ratio [OR], 23.28; 95% confidence interval [CI], 1.97 to 274.67; p = 0.012), both intra- and extrapelvic tumor extension (OR, 46.48; 95% CI, 3.50 to 617.77; p = 0.004), blood transfusion ≥20 units (OR, 50.28; 95% CI, 1.63 to 1550.32; p = 0.025), vascular sacrifice of the internal iliac artery (OR, 64.56; 95% CI, 6.33 to 658.43; p < 0.001), and use of a structural allograft (OR, 6.57; 95% CI, 1.70 to 25.34; p = 0.001) were significantly associated with postoperative wound complications.
Conclusions:
Internal hemipelvectomy is associated with high rates of morbidity, especially wound complications. Several host, tumor, and surgical variables are associated with wound complications. The ability to stratify patients by risk of wound complications can help refine surgical and wound-healing planning and may lead to better outcomes in patients undergoing internal hemipelvectomy.
INTRODUCTION
Limb-salvage surgery has been part of the standard oncologic treatment of malignant pelvic tumors and sarcomas of the extremities since the 1980s. Surgery for malignant pelvic tumors is challenging. This is due to their large size at diagnosis, the complex anatomy of the pelvis, and the close situation of vital organs such as vessels, nerve bundles, and viscera. Such surgery is accompanied by high rates of complications, including infection, wound dehiscence, hematoma or seroma formation, and skin necrosis.1–14 The majority of patients who experience complications require a second surgical procedure. This often leads to delayed postoperative chemotherapy and poor oncologic and functional outcomes.4,5,8,10
Few studies have examined the rate of wound complications or factors that increase the risk of wound complications in patients undergoing internal hemipelvectomy.5, 10, 15 In the present study, we aimed to (1) determine the rate of acute postoperative complications (wound complications and other complications requiring surgery) after internal hemipelvectomy, and (2) identify factors that affect the rate of wound complications and can be used to stratify patients by risk of wound complications.
PATIENTS AND METHODS
Patients treated with en bloc resection at Memorial Sloan Kettering Cancer Center (MSK) from 1996 to 2016 who presented with histologic confirmation diagnoses of pelvic malignancies were included in the study. Malignancies included bone and soft tissue sarcoma including primary and recurrent, solitary metastasis to the pelvis, and benign bone tumor with Enneking stage 3. Patients undergoing curettage were not eligible. One-hundred twenty-three patients undergoing limb salvage internal hemipelvectomy were retrospectively identified. Forty-two patients undergoing external hemipelvectomy were excluded from the analysis. Patients who did not experience complications were required to have follow-up of at least 12 months. The analysis reported in this study was approved by institutional review board protocol number 16–1123.
Patient demographic information (e.g., age at surgery, sex), tumor data (e.g., tumor size, histologic grade and diagnosis, presence of intra- or extrapelvic tumor extension), surgical details (e.g., operative duration, total blood loss and transfusion, type of resection, vascular sacrifice of internal iliac artery, reconstruction details), and adjuvant therapy details (e.g., chemotherapy and radiotherapy) were extracted from each patient’s electronic medical record. Type of resection was categorized according to the classification of pelvic resections proposed by Enneking et al.16 The total amount of blood transfusion was defined as the amount of blood transfused from the intraoperative period until 48 hours after the operation.
All patients had cephalosporin before incision, except penicillin allergic patients who received vancomycin. Doses were repeated every 3 hours for cephalosporin and every 6 hours for vancomycin. Antibiotics were continued until drains were removed. A mechanical bowel prep was prescribed the night before each surgery. Postoperative wound surveillance was performed periodically as described previously.17 Radiographic follow-up of bone and implant reconstructions was performed before leaving the hospital, at 6 weeks, 12 weeks, and then at intervals in keeping with National Comprehensive Network guidelines for the tissue diagnosis.18
The study endpoints were (1) rates of a postoperative wound complications (defined as any wound complication requiring surgery, such as wound dehiscence or infection), and (2) rates of other complications requiring surgical intervention. Antibiotic treatment alone without surgery would not be the basis for this study.
Wound dehiscence was defined as any persistent wound requiring surgical closure as described previously.19 Infection was defined as Grade 3 or 4 according to the classification of wound condition.17 The strategy for wound complications in MSK was as follows: 1) fascial dehiscence was treated surgically while superficial wound breakdown was treated with local irrigation and packing; 2) symptomatic seromas were evacuated by interventional radiology percutaneously, or in conjunction with diagnostic aspiration in the setting of persistent fever and concern about deep infection; and 3) all patients with deep infection underwent surgical debridement.
Statistical Analyses
Univariate and multivariate logistic regression analyses were performed to examine the association between each factor and the occurrence of postoperative wound complications requiring surgery. The number of variables which can be used in multivariate logistic regression analysis were estimated to avoid overfitting according to one -in-ten rule. When selecting specific variables used for multivariate analysis, clinical significance to avoid misspecification and variance inflation factor to avoid multicollinearity were considered. p <0.05 was considered to indicate statistical significance. Statistical analyses were performed using SPSS Statistics software (version 19, IBM, Armonk, NY).
RESULTS
Patient demographic, clinical, and histologic details are summarized in Table 1. In our cohort, 56 patients were male, and 67 were female. The mean age was 42.3 years (range, 5 to 79 years). All patients underwent limb-salvage internal hemipelvectomy for a pelvic tumor. Common histologic diagnoses were chondrosarcoma (n = 39), Ewing’s sarcoma (n = 21), cancer metastasis (n = 21), and osteosarcoma (n = 19). Fifty-four patients (43.9%) received chemotherapy, and 33 patients (26.8%) received radiotherapy. The mean follow-up period was 61 months.
Table 1.
Patient demographics and adjuvant therapy data.
| Characteristic | Number of patients (%) |
|---|---|
| Overall | 123 (100) |
| Age, years; mean [SDa] | 42.3 (range, 5–79) [20.1] |
| Sex | |
| Male | 56 (45.5) |
| Female | 67 (54.5) |
| Tumor size, cm; mean [SD] | 9.2 (range, 2.9–25.0) [4.5] |
| Histologic grade | |
| Benign, intermediate, low | 21 (17.1) |
| High | 102 (82.9) |
| Histologic diagnosis | |
| Chondrosarcoma | 39 (31.7) |
| Ewing’s sarcoma | 21 (17.1) |
| Cancer metastasis | 21 (17.1) |
| Osteosarcoma | 19 (15.4) |
| Bone involving soft tissue sarcoma | 11 (8.9) |
| Malignant fibrous histiocytoma of bone | 5 (4.1) |
| Other bone sarcoma | 4 (3.3) |
| Benign/intermediate tumor | 3 (2.4) |
| Tumor size, cm; mean [SD] | 11.4 (range, 4–25) [4.7] |
| Tumor extension | |
| Osseous | 31 (25.2) |
| Intrapelvic extension | 33 (26.8) |
| Extrapelvic extension | 22 (17.9) |
| Both | 37 (30.1) |
| Chemotherapy | 54 (43.9) |
| Radiotherapy | 33 (26.8) |
- SD, standard deviation.
Surgical details are listed in Table 2, and outcomes are listed in Table 3. Mean total operative time was 655 minutes (range, 120 to 1,626 min), and mean blood loss was 3,750 mL (range, 100 to 20,000 mL). Resection types, according to Enneking classification, were as follows: P1 (n = 55), P1+2 (n = 16), P1+2+3 (n = 8), P2 (n = 10), P2+3 (n = 17), and P3 (n = 17). Surgical margins were R0 in 102 patients (82.9%) and R1 in 21 (17.1%). The overall rate of postoperative complications requiring surgery was 49.6%. The most common issue were wound complications (n = 42 [34.1%]), including 3 cases with late infection. This was defined as infection more than 6 months postoperatively. Other complications were minor complications requiring surgery, such as compartment syndrome, ulcer due to protrusion of the remaining iliac bone, thrombus, or herniation of small intestine. Five patients necessitated external hemipelvectomy due to the uncontrolled infection (n = 4) or local recurrence (n = 1).
Table 2.
Surgical details of the patients.
| Characteristic | Number of patients (%) |
|---|---|
| Overall | 123 (100) |
| Operation time, mins; mean [SDa] | 654 (range, 120–1,626) [315] |
| Blood loss, mL; mean [SD] | 3750 (range, 100–20,000) [3574] |
| Blood transfusion, units; mean [SD] | 11.7 (range, 0–66) [12.3] |
| Resection type | |
| P1 | 55 (44.7) |
| P12 | 16 (13.0) |
| P123 | 8 (6.5) |
| P2 | 10 (8.1) |
| P23 | 17 (13.8) |
| P3 | 17 (13.8) |
| Sacrifice of internal iliac vessels | 23 (18.7) |
| Bony reconstruction | 77 (62.6) |
| No reconstruction | 46 (37.4) |
| Prosthesis | 35 (28.5) |
| Structural allograft | 17 (13.8) |
| Surgical margin | |
| R0 | 102 (82.9) |
| R1 | 21 (17.1) |
- SD, standard deviation
Table 3.
Postoperative complications requiring surgery
| Characteristic | Number of patients (%) |
|---|---|
| Overall postoperative complications | 61 (49.6) |
| Wound complications | 42 (34.1) |
| Hardware related complications | 10 (13.2) |
| Graft related complications | 5 (9.1) |
| Local recurrence | 7 (5.7) |
| Other complications | 18 (14.6) |
| Amputation during follow-up | 5 (4.1) |
Table 4 shows postoperative complications by subgroup. On univariate analysis, none of the host factors, including sex, age, chemotherapy, and radiotherapy, were significantly associated with wound complications. Among the tumor factors, larger tumor size (> 8 cm; p = 0.050), high histologic grade (p = 0.045), and extraosseous tumor extension (intrapelvic extension [p = 0.039], extrapelvic tumor extension [p = 0.004], and both intra- and extrapelvic tumor extension [p < 0.001]) were significantly associated with higher postoperative complication rates. Among surgical factors, longer operative time (≥ 6 hours to < 12 hours [p = 0.024] and ≥12 hours [p = 0.003]), massive blood transfusion (10–19 units [p = 0.042] and ≥ 20 units [p = 0.004]), resection type other than P1 or P3 (p = 0.013), vascular sacrifice of the internal iliac artery (p < 0.001), and use of a structural allograft (p = 0.026) were significantly associated with wound complications.
Table 4.
Univariate and multivariate logistic regression analyses for postoperative wound complication
| Number of patients | Number of patients with wound complications (%) | Univariate analysis | Multivariate analysis | |||
|---|---|---|---|---|---|---|
| Odds ratio (95% CIa) | p value | Odds ratio (95% CI) | p value | |||
| Total number of patients | 123 | 42 (34.1%) | ||||
| Sex | ||||||
| Male | 56 | 16 (28.6%) | Reference | |||
| Female | 67 | 26 (38.8%) | 1.56 (0.74–3.39) | 0.235 | ||
| Age | ||||||
| ≤ 39 | 57 | 19 (33.3%) | Reference | |||
| 40–64 | 42 | 12 (28.6%) | 0.80 (0.34–1.90) | 0.614 | ||
| ≥ 65 | 24 | 11 (45.8%) | 1.69 (0.64–4.48) | 0.290 | ||
| Tumor size | ||||||
| ≤ 8cm | 60 | 15 (25.0%) | Reference | |||
| > 8cm | 62 | 26 (41.9%) | 2.17 (1.01–4.69) | 0.050 | ||
| Histologic grade | ||||||
| Low | 21 | 3 (14.3%) | Reference | |||
| High | 102 | 39 (38.2%) | 3.71 (1.03–13.44) | 0.045 | ||
| Tumor extension | ||||||
| Intraosseous | 31 | 15 (3.2%) | Reference | Reference | ||
| Intrapelvic | 33 | 26 (24.2%) | 9.60 (1.12–82.05) | 0.039 | 6.16 (0.59–64.23) | 0.129 |
| Extrapelvic | 22 | 39 (45.5%) | 25.00 (2.88–217.19) | 0.004 | 23.28 (1.97–274.67) | 0.012 |
| Both | 37 | 23 (62.2%) | 49.29 (6.03–402.56) | <0.001 | 46.48 (3.50–617.77) | 0.004 |
| Chemotherapy | ||||||
| No | 69 | 19 (27.5%) | Reference | |||
| Yes | 54 | 23 (42.6%) | 1.95 (0.92–4.15) | 0.082 | ||
| Radiotherapy | ||||||
| No | 90 | 28 (31.1%) | Reference | |||
| Yes | 33 | 14 (42.4%) | 1.63 (0.72–3.71) | 0.243 | ||
| Operation time | ||||||
| < 6 hours | 24 | 1 (4.2%) | Reference | |||
| ≥ 6, < 12 hours | 49 | 16 (32.7%) | 11.15 (1.38–90.09) | 0.024 | ||
| ≥12 hours | 50 | 25 (50.0%) | 23.00 (2.88–183.63) | 0.003 | ||
| Blood transfusion | ||||||
| No | 17 | 13 (5.9%) | Reference | Reference | ||
| 1–9 units | 53 | 29 (26.4%) | 5.74 (0.70–47.40) | 0.105 | 11.16 (0.43–289.72) | 0.147 |
| 10–19 units | 21 | 15 (38.1%) | 9.85 (1.09–89.21) | 0.042 | 8.37 (0.27–258.53) | 0.225 |
| ≥ 20 units | 32 | 19 (59.4%) | 23.39 (2.75–198.74) | 0.004 | 50.28 (1.63–1550.32) | 0.025 |
| Resection type | ||||||
| P1 | 35 | 3 (22.9%) | 4.74 (0.54–41.47) | 0.160 | ||
| P3 | 17 | 39 (5.9%) | Reference | |||
| Others | 71 | 33 (46.5%) | 13.90 (1.75–110.49) | 0.013 | ||
| Vascular sacrifice (internal iliac artery) | ||||||
| No | 100 | 20 (20.0%) | Reference | Reference | ||
| Yes | 23 | 22 (95.7%) | 88.00 (11.18–692.55) | <0.001 | 64.56 (6.33–658.43) | < 0.001 |
| Prosthesis | ||||||
| No | 88 | 27 (30.7%) | Reference | |||
| Yes | 35 | 15 (42.9%) | 1.69 (0.76–3.80) | 0.201 | ||
| Structural allograft | ||||||
| No | 106 | 32 (20.0%) | Reference | Reference | ||
| Yes | 17 | 10 (58.8%) | 3.30 (1.16–9.45) | 0.026 | 6.57 (1.70–25.34) | 0.001 |
- CI, confidence interval.
Based on the one-in-ten rule, the appropriate number of variables to use for multivariate analysis was considered to be four. Because our hypothesis was extraosseous soft tissue extension and was a strong predictor for wound complications, this variable was chosen for multivariate analysis. The other 3 variables for multivariate analysis were selected based on variance inflation factor, as well as statistical and clinical significance.
On multivariate analysis, extrapelvic tumor extension (odds ratio [OR], 23.28; 95% confidence interval [CI], 1.97 to 274.67; p = 0.012), both intra- and extrapelvic tumor extension (OR, 46.48; 95% CI, 3.50 to 617.77; p = 0.004), blood transfusion of ≥ 20 units (OR, 50.28; 95% CI, 1.63 to 1550.32; p = 0.025), vascular sacrifice of the internal iliac artery (OR, 64.56; 95% CI, 6.33 to 658.43; p < 0.001), and use of a structural allograft (OR, 6.57; 95% CI, 1.70 to 25.34; p = 0.001) were significantly associated with higher postoperative wound complication rates.
DISCUSSION
The development of effective chemotherapy options and advanced imaging techniques has facilitated limb-salvage surgery for patients with sarcoma of the pelvic area. This has led to increased use of internal hemipelvectomy during the last two decades. Despite treatment advances, limb-salvage surgery for pelvic tumors remains one of the most technically challenging procedures for orthopaedic oncologists. High rates of complications persist, especially wound complications.5, 10, 15 However, data on rates of and risk factors for wound complications following internal hemipelvectomy are limited. Only three studies have analyzed postoperative wound complications after pelvic tumor surgery in more than 100 cases (Table 5).5,10 Senchenkov et al. analyzed 160 patients (127 with sarcoma and 33 with other conditions) undergoing external hemipelvectomy.10 They found that wound complications were the most common morbidity (39%), and operative time (> 75 percentile) and extended resection were significantly associated with wound complications.10 In an analysis of 110 patients undergoing external or internal hemipelvectomy from Hillmann et al., wound complications were the most common morbidity (40%).5 However, this study did not report risk factors for wound complications. The largest study so far is a reported by Angelini et al., which analyzed 270 patients undergoing internal hemipelvectomy.15 The rate of deep infection was 20% at a mean follow-up of 8 months. They demonstrated only reconstruction to be a significant risk factor for deep infection with rates of 15% without reconstruction and 26% with reconstruction, respectively. Other potential risk factors for deep infection, including host factors (age, comorbidity, body mass index, etc.), treatment (chemotherapy and radiotherapy), tumor factors (tumor size, histologic grade, soft tissue extension, etc.), and surgical factors (operative time, transfusion, type of resection, vascular sacrifice of internal iliac artery, use of prosthesis or allograft, etc.) were not significant. In the current study wound complications were the most common morbidity (34.1%), which is consistent with studies above. In addition, several factors were associated with wound complications following internal hemipelvectomy, including extraosseous tumor extension, massive blood transfusion, vascular sacrifice of the internal iliac artery, and use of a structural allograft.
Table 5.
Summary of the major previous reports focusing on postoperative complications
| Report | Hemipelvectomy type | Number of cases | Overall complication rate (%) | Wound complication rate (%) | Risk factors for wound complications |
|---|---|---|---|---|---|
| Senchenkov et al.10 | External | 160 | NRa | 39% | Operation time |
| Extended resection | |||||
| Hillmann et al.5 | External and internal | 110 | 50% | 40% | NR |
| Angelini et al.15 | Internal | 270 | NR | 20% | Reconstruction |
| Current study | Internal | 123 | 50% | 34% | Tumor extension |
| Massive transfusion | |||||
| Use of structural allograft | |||||
| Vascular sacrifice |
- NR, not reported
Although it is widely believed among orthopaedic oncologists that preservation of the internal iliac artery is critical for decreasing the risk of wound necrosis and dehiscence (which can lead to deep infection), this has not been validated in a large study. In this cohort, vascular sacrifice of the internal iliac artery was an independent risk factor for wound complications after internal hemipelvectomy, with a surprisingly high frequency (22 of 23 patients [95.7%]). This finding strongly suggests that wound complications should be expected in cases where the internal iliac artery is sacrificed.
The relationship between local cancer control, surgical margin, normal tissue sacrifice, and local complication rate is a perennial concern among orthopaedic surgeons. The rate of local recurrence in the current study was low. This did not appear to be attributable to more-aggressive removal of uninvolved soft tissue, since the local complication rate was equivalent to those reported in the two other large studies.5, 10 Alternatively, it could be interpreted that good local sarcoma control rates can be achieved by means of surgical margins that do not result in a higher wound complication rate than those reported in series with higher local recurrence rates. However, it should be noted that rates of local recurrence in our cohort may increase with longer follow-up time.
This study has several limitations. First, it is retrospective in design. Second, the sample size is relatively small for evaluation of the potential independent variables analyzed, as internal hemipelvectomy is warranted for only a limited number of presentations. Patient numbers will always be small, as was the case in previous studies.5, 10, 15 However, there were ample patients to evaluate the primary and secondary outcome variables.
In conclusion, using the MSK cohort, high rates of overall and wound complications after internal hemipelvectomy were observed. Several independent risk factors for wound complications can stratify high risk patients with wound complications. Accurate stratification of patients undergoing internal hemipelvectomy may help select the optimal surgical procedure and wound-healing approach, thereby lowering rates of postoperative complications and improving outcomes in these patients.
FUNDING
This study was funded by the Pearlman Limb Preservation Fund at MSK and was also funded in part through the NIH/NCI Cancer Center Support Grant, P30 CA008748.
Footnotes
CONFLICT OF INTEREST STATEMENT
The authors have no conflicts of interest. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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