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Clin Orthop Relat Res (2018) 476:1762-1770
DOI 10.1007/s11999.0000000000000165
2017 International Society of Limb Salvage Proceedings
Upshifting the Ipsilateral Proximal Femur May Provide
Satisfactory Reconstruction of Periacetabular Pelvic Bone
Defects After Tumor Resection
Nong Lin MD, Hengyuan Li MD, Weixu Li PhD, Xin Huang MD, Meng Liu MD, Xiaobo Yan MD,
Weibo Pan MD, Disheng Yang PhD, Zhaoming Ye PhD
Received: 31 July 2017 / revised: 7 December 2017 / Accepted: 18 December 2017 / Published online: 20 February 2018
Copyright © 2018 by the Association of Bone and Joint Surgeons
Abstract
Background Pelvic ring reconstruction after resection of
pelvic malignancies or aggressive benign tumors
remains challenging, especially when the tumor invades
periacetabular bone, resulting in a Type II resection as
classified by Enneking and Dunham (removal of part or
all of the acetabulum). Although numerous treatment
approaches are in use, none is clearly superior to the
others. An alternative involving use of the ipsilateral
proximal femur as an autograft has not been well char-
acterized, so we present our preliminary experience with
this approach.
Questions/purposes (1) What were the oncologic out-
comes after using an ipsilateral proximal femur autograft for
reconstruction after Type II pelvic resection in a small series
of patients who underwent this reconstructive approach? (2)
What were the Musculoskeletal Tumor Society (MSTS)
scores after this reconstruction? (3) What complications
were observed?
Methods Between October 2006 and May 2016, we trea-
ted 67 patients with Type II malignant or aggressive benign
tumors of the ilium. Of those, we used an ipsilateral
proximal femur and a prosthesis as a reconstruction method
for 11 patients with pelvic tumors. In general, we per-
formed this approach in young or middle-aged patients
with primary malignant or aggressive benign tumors in-
volving pelvic area II and in whom the tumor did not in-
vade the hip. The method used for resection of pelvic
tumors included osteotomy of the femoral shaft, harvesting
the proximal femur as a graft. The length of the femoral
graft was determined by the extent of the pelvic defect. The
proper placement was selected after a comparison of the
proximal femur and the pelvic defect. A curved
Each author certifies that neither he or she, nor any member of his or her immediate family, has funding or commercial associations
(consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are
encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.
Each author certifies that his or her institution approved the human protocol for this investigation and that all investigations were
conducted in conformity with ethical principles of research.
Nong Lin and Hengyuan Li contributed equally to this work.
Department of Orthopedics, Second Affiliated Hospital of Zhejiang University School of Medicine/Orthopedics Research Institute of Zhejiang
University, Zhejiang, China
Z. Ye ✉, Department of Orthopedics, Second Affiliated Hospital of Zhejiang University School of Medicine, No. 1511, Jianghong Road,
Hangzhou 310000, China, email: yezhaoming@zju.edu.cn
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with
the publication and can be viewed on request.
Copyright Ó2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
reconstruction plate and cancellous bone screws were used
for pelvic fixation. The operative duration and total blood
loss were recorded. Of the 11 patients who underwent this
approach, all but one had at least 2 years of followup unless
death occurred earlier, and all but one have been seen
within the last year for evaluation. Functional outcomes
were assessed using the MSTS scoring system. Local re-
currence, metastases, and deaths were recorded as were
complications including infection, bone nonunion, me-
chanical failure and sciatic nerve palsy.
Results The followup was a mean of 37 months (range,
13-96 months). One patient was lost to followup. Three
patients died of disease owing to local recurrence or lung
metastasis. The other seven patients lived without evi-
dence of tumor. The main complications included me-
chanical failure in two patients, nonunion in one patient,
infection in two patients, and sciatic nerve palsy in one
patient. The median MSTS function score was 70% (21
of 30 points; range, 11-25 points).
Conclusions Our preliminary results show that this tech-
nique of using the ipsilateral proximal femur may be an
alternative method for reconstruction of pelvic bone
defects after tumor resection. Even with this short fol-
lowup, complications were common, but short-term func-
tion appears to be comparable to studies of other options.
Longer term followup with more patients is necessary to
confirm our results.
Level of Evidence: Level IV, therapeutic study.
Introduction
Pelvic ring reconstruction after resection of pelvic bone
tumors is challenging. When the tumor involves the ace-
tabulum (Type II resection [9]), the hip is often recon-
structed if the patient is to have a strong likelihood of being
able to walk, although there are reports of reasonable
function with no reconstruction and a flail hip [13,21];
current methods for pelvic ring reconstruction include
customized or modular hemipelvic prostheses, saddle
prostheses, pelvic allografts, or allograft-prosthetic recon-
structions [2,7,15,20]. However, there is no agreement on
which reconstructive approach might be superior, and all
have shortcomings [2,7,22].
Biologic pelvic reconstruction has the potential advantage
of long-term pelvic stability but is associated with a high
likelihood of complications [14,26]. In the 1980s, Puget and
Uth´
eza [19] proposed an innovative approach: upshifting the
ipsilateral proximal femur. They procured the proximal part of
the ipsilateral femur to replace the resected pelvic bone and
fixed it to the remaining bone by screws and plates. An ace-
tabular cup was cemented into the transplanted bone, which
itself was replaced by a femoral prosthesis (Fig. 1A-C). The
goals of this technique are to ensure long-term fixation
through integration of a cortical-cancellous autograft because
of restored pelvic continuity and to implant a more conven-
tional total hip prosthesis in the appropriate anatomic position
in an attempt to optimize function [17]. In this study, we
reviewed our preliminary experience in 11 patients with
pelvic malignancies or aggressive benign tumors who un-
derwent ipsilateral proximal femoral autograft reconstruction.
We sought to describe the surgical procedure in detail and
report on the oncologic and functional outcomes.
Specifically, we asked the following questions: (1)
What were the oncologic outcomes after using an ipsilat-
eral proximal femur autograft for reconstruction after Type
II pelvic resection in a small series of patients who un-
derwent this reconstructive approach? (2) What were the
Musculoskeletal Tumor Society (MSTS) scores after this
reconstruction? (3) What complications were observed?
Patients and Methods
The retrospective study was approved by the Human
Research Ethics Committee of our hospital. Between
October 2006 and May 2016, 67 patients were treated for
malignant or aggressive benign tumors involving the
acetabulum (Type II resections as definedbyEnneking
and Dunham [9]). Of these, 11 patients underwent hem-
ipelvic resection, reconstruction of the pelvic ring by
upshifting the ipsilateral proximal femur, and re-
constructionofthehipwithatumor-typedproximalfe-
mur prosthesis (Table 1; Fig. 1).
The indications for selecting this reconstruction were young
or middle-aged patients with primary malignant or aggressive
benign pelvic tumors involving zone II that did not directly
involve the hip, including isolated acetabular tumors, tumors
that extended into the obturator ring (zone II + III), the wing of
the ilium (zone I + II), and even all three zones. It was espe-
cially useful when part of the acetabulum remained (so-called
partial Type II resection), because in these patients, it was
easier to anchor the proximal femur to the pelvis. During the
period in question, we considered a number of other
approaches for reconstruction among our patients who un-
derwent Type II resections. Fifty-six patients underwent Type
II resections and were treated in other ways includ-
ing amputation, no reconstruction (flail hip), and reconstruction
by artificial hemipelvic prosthesis. In terms of our experience,
the following four key dimensions need to be considered when
upshifting the ipsilateral proximal femur. First, we consider age
and tumor type. This technique is associated with a relatively
long time to achieve bone healing. We therefore thought it was
not applicable to older patients (> 60 years old) with poor
ability of bone healing and those with a short life expectancy
(metastatic tumor). Instead, a hemipelvic prosthesis or no
Volume 476, Number 9 Upshifting Proximal Femur 1763
Copyright Ó2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
reconstruction was considered for those patients. Second, for
patients with a pelvic tumor extensively involving zone I in
addition to zone II, it was a great challenge to use the traditional
pelvic prosthesis, so the upshifting approach seemed more
appropriate to us. Apart from a three-dimensional-printed
prosthesis, upshifting the proximal femur for reconstruction
seemed a good choice. Third, the desires and cooperation of the
patient were considered. Compared with reconstruction after
tumor resection, no reconstruction with a flail hip was a choice
with a low incidence of complications. If patients were un-
willing to take risks of postoperative complications and were
able to accept the problems with hip function and leg length
discrepancy, we would not use this technique. Fourth, we fa-
vored this reconstruction if part of the acetabulum remained.
This technique was especially appropriate if part of the ace-
tabulum remained (so-called partial Type II resection), because
in these patients, it was easier to anchor the proximal femur to
the pelvis, its location was easier to determine, and less bone
graft was needed.
The primary tumor types included seven patients with
chondrosarcoma, two patients with primitive neuro-
ectodermal tumor/Ewing’s sarcoma, and two patients with
giant cell tumor. Five patients with tumor involved pelvic
area I + II, four involved pelvic area II + III, one involved
pelvic I + II + III, and one involved pelvic II (Table 1).
Surgical Technique
The method used for the resection of pelvic tumors was the
same as that used in prior reports [9,16]. The patients were
lying in a sloppy lateral position. A curved incision was made
from the pubic symphysis through the groin and along the iliac
crest to the sacroiliac joint. A second incision was made from
the iliac spine to the greater trochanter that extended along the
direction of the femur to the midthigh. Flaps were made to
dissect the tumor and expose the pelvis for osteotomies.
Osteotomies were performed in the ilium and pubis and/or
ischium depending on the extent of the tumor. The proximal
femur was exposed through the lateral incision. The vastus
lateralis muscle was dissected from the femoral shaft and the
iliopsoas tendon was released from the lesser trochanter. The
osteotomy level of the femoral shaft was determined by
the extent of the pelvic defect to obtain enough graft to fill the
Fig. 1A-E We created a drawing to show pelvic reconstruction after tumor resection with an ipsilateral proximal femur. (A) The
pelvic tumor is resected with a bone defect (zone I + II). (B) The ipsilateral proximal femur is harvested and transferred to fill the
space. (C) The hip is rebuilt with a femoral prosthesis. (D-E) The hip capsule is reconstructed with hernia mesh to prevent dislocation.
We crossed the mesh through the pelvic ring and sutured its ends to the proximal prosthesis.
1764 Lin et al. Clinical Orthopaedics and Related Research
®
Copyright Ó2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
defect. The proximal femur, including the femoral head and
intertrochanteric region and sufficient shaft, was used as a graft.
The proper direction and angle were selected after comparison
of the proximal femur and the pelvic defects. If possible, the
remaining acetabulum was used as a reference to locate the
acetabulum region in the intertrochanteric area. A curved re-
construction plate and cancellous bone screws were used for
pelvic fixation. Attempts were made to avoid gaps at the
junctions to provide good bone-on-bone contact. Large
defects were filled with cancellous bone obtained from the
intertrochanteric area of the femur. The new acetabulum was
reamed as close to the original location of the acetabulum as
possible. If possible, the remaining acetabulum was used as
a reference to control the direction and depth of the acetabu-
lum. An X-CHANGE reinforcement ring (Howmedica
Osteonics Corp, Mahwah, NJ, USA) was used in one patient
(Fig. 2). The acetabular cup was cemented on the newly
reamed femoral "acetabulum." A proximal femoral prosthesis
was implanted in the proximal femoral canal after the canal
was reamed. The hip was repositioned. The capsule was
reconstructed with hernia mesh to prevent dislocation of the
femoral prosthesis (Fig. 2). In detail, the hernia mesh was
folded into a rectangle. Then we crossed the mesh through the
pelvic ring and sutured its two ends to the proximal femoral
prosthesis, which served as a new artificial hip capsule (Fig.
1D-E). The iliopsoas residual was sutured to the hole of the
prosthesis. The gluteus medius was sutured to the vastus lat-
eralis and reinforced by suturing it to a hole on the greater
trochanter of the prosthesis. Three suction drainage tubes were
routinely placed before the incision was closed.
Postoperatively, three drains were maintained until the
volume of drainage was < 50 mL per day. Intravenous
antibiotic treatment was maintained for 2 weeks after surgery.
Patients were immobilized in bed for 8 weeks and partial
weightbearing using crutches was started 8 weeks after sur-
gery. Full weightbearing was not allowed until bone union of
the pelvic ring was seen on plain radiographs and CT scans at
followup. All patients were followed up at 1 month, 3 months,
and every 3 months for the first 2 years, every 6 months
between 2 and 5 years, and yearly thereafter. The average
followup was 37 months (range, 13-96 months). One patient
was lost to followup 46 months after surgery.
Local recurrence was screened by history and examina-
tion, radiographs, and bone scans. The presence of metastasis
was determined by routine chest CT scan and bone scan at 3
and 6 monthly intervals separately. The functional outcomes,
which included pain, function, emotional acceptance, sup-
port, walking ability, and gait, were assessed with the 1993
MSTS system [8] by chart review at last followup (data were
collected when the patients were still surviving for the ones
who died). Chart review was performed by a physician (YL)
who was not involved in the care of the patients.
Results
At last followup, two patients (Patients 3 and 5) experienced
local recurrences and two developed lung metastasis (Patients
1 and 5). Three patients (Patients 1, 3, and 5) had died of the
disease 39 months, 28 months, and 13 months after surgery
separately. One patient (Patient 4) was lost to followup 46
months after surgery. The other seven patients lived without
evidence of tumor (Table 2).
Table 1. Patient information
Patient
number
Age
(years) Gender
Type of
tumor Location
Type of
prosthesis
Acetabular
cup
(type and size [mm])
Length of
femoral
osteotomy
(cm)
Use of
hernia
mesh
1 55 Female Chondrosarcoma II + III LINK(SPII) LINK 44 13 No
2 26 Male PNET I + II LINK(SPII) LINK 44 12 No
3 19 Male PNET II + III Chunli(C) DePuy 43 15 No
4 32 Female Chondrosarcoma I + II LINK(SPII) LINK 44 14 No
5 21 Male Chondrosarcoma I + II Chunli(M) DePuy 43 12 No
6 39 Male Chondrosarcoma II + III Chunli(M) Chunli 44 14 Yes
7 52 Male Chondrosarcoma II + III Chunli(M) DePuy 43 13 Yes
8 41 Female Chondrosarcoma I + II Chunli(M) DePuy 43 13 Yes
9 52 Female Chondrosarcoma I + II Chunli(M) DePuy 43 14 Yes
10 53 Male GCT I + II + III Chunli(M) Chunli 44 14 Yes
11 22 Male GCT II Chunli(M) Chunli 44 12 Yes
PNET = primitive neuroectodermal tumor; GCT = giant cell tumor; type of prosthesis: Chunli Co, Beijing, China; LINK, Hamburg,
Germany; type of hernia mesh: DePuy (PMM3), New Brunswick, NJ, USA; Chunli(C) = customized hip prosthesis of Chunli;
Chunli(M) = modular hip prosthesis of Chunli; LINK(SPII) = SPII(R) Long Prosthesis of LINK.
Volume 476, Number 9 Upshifting Proximal Femur 1765
Copyright Ó2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
The median MSTS 93 score was 70% (21 of 30 points;
range, 11-25 points). All but one (Patient 11) had at least 2
years of followup unless death occurred earlier, and all but
one (Patient 4 lost to followup) have been seen within the
last year for evaluation. We provided gait videos of seven
patients (Patients 1, 2, 6-10) to show postoperative func-
tion. In these videos, patients could walk without assistance
(see Supplemental Digital Content 1,Supplemental Digital
Content 2,Supplemental Digital Content 3,Supplemental
Digital Content 4,Supplemental Digital Content 5,
Supplemental Digital Content 6,andSupplemental Digital
Content 7).
The main complications included mechanical failure
(two patients), nonunion (one patient), infection (two
patients), and sciatic nerve palsy (one patient). One pa-
tient experienced a local superficial infection 1 month
after surgery and was successfully treated by dressing
changes and antibiotics with good functional recovery
(Patient 1). One patient sustained a deep infection 44
months after surgery and was treated with d´
ebridement
and original implants were retained (Patient 6). One
patient experienced postoperative sciatic nerve palsy and
bone nonunion 15 months after surgery. The internal
fixation was broken. No treatment was administered with
no recovery of the nerve function (Patient 3). One patient
experienced loosening of the acetabular prosthesis
26 months after surgery, and a revision operation was
performed. The patient was alive without evidence of
tumoratlastfollowupbeforeshewaslost(Patient4).
Discussion
Reconstruction after resection of a periacetabular tumor is
one of the most technically demanding procedures in or-
thopaedic oncology. Various methods of pelvic re-
construction after tumor resection have emerged,
including customized pelvic prostheses, modular pelvic
prostheses, allografts with or without prostheses, reim-
plantation of autologous pelvic bone after devitalization
of the pelvic bone tumor, and autologous fibular grafting
Fig. 2A-H Patient 9 was a 52-year-old woman who had a chondrosarcoma of the pelvis (zone I + II). She underwent pelvic
reconstruction by upshifting the ipsilateral proximal femur after tumor resection. (A-C) Radiograph, CT, and MR images show
a chondrosarcoma in the pelvis. Intraoperative photographs show (D) the proximal femur was fixed to the pelvic ring and the
acetabulum was built; (E) the hip was repositioned and the capsule was reconstructed with hernia mesh (black arrow). (F) Fifteen
months after the operation, the prosthesis was stable. (G-H) CT scan demonstrates that the autograft has united to the pelvis.
1766 Lin et al. Clinical Orthopaedics and Related Research
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Copyright Ó2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
[2,7,15,25,26]. Hemipelvic prostheses have been the
preferred option for the reconstruction of large defects by
some centers [7,15,23]. In the 1980s, Puget and Uth´
eza
[19] proposed to treat bone defects after pelvic tumor
resection with reconstruction of the pelvic ring by
upshifting the ipsilateral proximal femur. This technique
aimed to restore the continuity of the pelvic ring with
a femoral autograft and to implant a more conventional
femoral prosthesis in the appropriate anatomic position in
an attempt to optimize function. In our small series, the
resected ipsilateral proximal femur was upshifted for
pelvic reconstruction, an approach we believe is advan-
tageous for several reasons. First, compared with pelvic
prostheses, it restores the continuity of the pelvic ring
owing to the natural curvature of the proximal femur that
fits adequately into the defect, giving a good chance for
a stable, biologic pelvic ring in the long term. Limb length
discrepancy is avoided in comparison with a flail hip or
hip transposition. Second, this technique is adapted for
extensive defects in zone I combined zone II, in which it is
a great challenge for pelvic prostheses as a result of lack of
a bone block. Third, femoral autograft instead of allograft
could result in a lower infection rate. A massive allograft
is very attractive because it provides anatomic recon-
struction. Nevertheless, a limited source of bone bank,
fracture, infection, transmission of infectious diseases,
and the absence of incorporation in the long term are
issues that deter some surgeons from using allografts.
However, the major disadvantage of upshifting the proximal
femur lies in the disturbance of gait owing to loss of the bony
attachment of the gluteus in the greater trochanter of the
femur. However, that is not apparent when tumor invades
Table 2. Followup results
Patient
number
Surgery
duration
(hours)
Blood
loss during
surgery (mL)
Followup
(months) MSTS score Complications
Results at
last followup
1 7.5 3000 39 21 Infection 1 month after surgery;
conservative treatment; lung
metastasis 30 months after surgery
Death
2 6 1400 96 25 None Living tumor-
free
3 7 5500 28 11 Postoperative sciatic nerve palsy; the
internal fixation was broken, and the
bone graft was found not to be
healing at 15 months; local tumor
recurrence at 18 months
Death
4 6.5 3500 46 17 Loosening of the prosthesis with
revision surgery performed 26 months
after the original surgery
Living tumor-
free
5 6 1600 13 22 Local tumor recurrence 6 months after
surgery; amputation was performed;
lung metastasis 10 months after
surgery
Death
6 6 1200 60 21 Deep infection 44 months after
surgery; d´
ebridement and antibiotics
with implants reserved
Living tumor-
free
7 7 1000 35 23 None Living tumor-
free
8 6.5 800 25 20 None Living tumor-
free
9 7 1500 24 21 Fracture of tibial plateau at the same
side happened 14 months after
surgery; ORIF was performed
Living tumor-
free
10 7 1200 24 25 None Living tumor-
free
11 6 900 21 24 None Living tumor-
free
The average surgery duration was 6.6 hours and the average blood loss during surgery was 1964 mL; MSTS = Musculoskeletal Tumor
Society; ORIF = open reduction and internal fixation.
Volume 476, Number 9 Upshifting Proximal Femur 1767
Copyright Ó2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
zone I combined zone II, in which the origin of the gluteus
has to be resected. Our preliminary findings suggest that
upshifting the ipsilateral proximal femur may be a reasonable
option for combined Type II and II defects and combined
Type I and II defects. However, we did observe many
complications, and function in the short term seems com-
parable to other approaches.
Our findings need to be interpreted in light of the fol-
lowing limitations. First, the number of patients is small,
and so the degree to which the findings might generalize to
different patients or different tumors is unknown. Second,
there was no group of pelvic prostheses for comparison, but
there are published outcomes using the pelvic prosthesis,
which we discuss subsequently, that can serve as a basis for
comparison. Related to that, in a retrospective study, there
always is the issue of selection bias. Other treatments in-
cluding amputation, no reconstruction, and hemipelvic
prostheses were used during this time for patients with
Type II resections. In general, we used upshifting of the
proximal femur in young or middle-aged patients with
primary malignant or aggressive benign tumors involving
pelvic zone II; it is especially useful when part of the ac-
etabulum remains. Third, the followup is short; it is pos-
sible, and perhaps likely, that more complications will
accrue and more revision procedures may be performed,
reflecting the complex nature of these reconstructions. Fi-
nally, there is no perfect way to measure function in such
a heterogeneous group of patients with complex recon-
structions; we have used the MSTS score, which is not as
detailed perhaps as it could be. However, we supplement
that with videos of seven of our patients (see Supplemental
Digital Content 1,Supplemental Digital Content 2,
Supplemental Digital Content 3,Supplemental Digital
Content 4,Supplemental Digital Content 5,Supplemental
Digital Content 6, and Supplemental Digital Content 7).
We found we could achieve adequate local control using
this approach. We observed two (18%) local recurrences and
two (18%) lung metastases. Three patients (27%) died 39
months, 28 months, and 13 months after surgery separately.
One patient was lost to followup 46 months after surgery. The
other seven patients (63%) remained disease-free. The result of
local tumor control in our series is comparable to results in
other reports. Ji et al. [15] retrospectively reviewed 100 patients
who were treated by reconstruction with modular hemipelvic
endoprostheses. They reported that 20 patients (20%) had local
recurrence, 28 patients (28%) developed distant metastasis, 36
patients (36%) died, and 58 patients (58%) were disease-free.
Guo et al. [10] examined 45 patients with pelvic chon-
drosarcoma involving the periacetabulum who received re-
construction of modular hemipelvic endoprostheses, saddle
endoprostheses, devitalized tumor bone, or iliofemoral
arthrodeses. The proportions of both local recurrence and dis-
tant metastasis were 22.2%. Thirty patients (66.7%) were alive
without evidence of disease.
The short-term functional scores from the followup in this
study appear to be comparable to those of pelvic prostheses
reported by others [4,12,15]. Further observation is required
to determine the long-term effects. The median MSTS score
was 70% (21 of 30 points; range, 11-25 points) in our series,
in keeping with the results of other reconstruction methods,
andnoreconstructionwithaflail hip or hip transposition has
a stable long-term effect with few complications. Schwartz
et al. [21] reported on resection arthroplasty of the hemipelvis
and found a mean MSTS score of 73.3% (22 of 30 points;
range, 53.3%-80%) for eight patients after a mean followup of
9.8 years. Hoffmann et al. [13] compared the function of
endoprosthetic replacement and hip transposition and found
better functional results in a hip transposition group with
a mean score of 60.7% (range, 16.6%-83.3%). However, limb
length discrepancy was a major concern, ranging from 2 cm to
12 cm [13,18]. The MSTS score in patients with modular
endoprostheses ranged from 57.2% to 63.3% [10,11,15]. On
the other hand, the function with some other new endopros-
theses including LUMiC(R) (implantcast, Buxtehude, Ger-
many) [4], ice cream cone [1], and pedestal cup [12]ranged
from 63.3% to 71%. Biologic reconstruction is advocated
because of its good biocompatibility and the ability to restore
the continuity of the pelvic ring. Wafa et al. [26]usedextra-
corporeally irradiated autografts for pelvic reconstruction in
16 patients and reported the mean MSTS score was 77%
(range, 50%-90%). Tang et al. [24] retrospectively reviewed
13 patients with bulk femoral head autografts and found
a high mean MSTS score of 83% (range, 63%-97%). In an-
other study [17] involving 10 patients with proximal femur for
reconstruction, similar in some ways to the approach we used,
the mean MSTS score was also generally high, 83% (range,
67%-97%). In our study, most patients could walk without
support. However, the interference with gait is inevitable as
a result of loss of the bony attachment of the gluteus to the
greater trochanter of the femur.
The main complications in our series were superficial
or deep infection (18%), mechanical failure (18%),
nonunion (9%), and sciatic nerve palsy (9%), but there
was no dislocation. The complications associated with
other reconstruction methods vary with the type of im-
plant. Massive allografts are a valid reconstructive op-
tion and are associated with complications such as
infection, dislocation, sciatic nerve palsy, and nonunion.
Delloye et al. [6] reviewed 24 patients with pelvic allo-
graft and reported five infections (21%), six neurologic
deficits (25%), two dislocations (8%), and three non-
unions (13%). In another study [5] of 33 patients with
massive allograft, five infections (15%), six hip dis-
locations (18%), and eight sciatic nerve palsies (24%)
were reported. Prosthetic reconstructions, including
custom-made, modular prosthesis, saddle and pedestal
cup, are generally the preferred approach with satisfac-
tory functional recovery in the short term. However, they
1768 Lin et al. Clinical Orthopaedics and Related Research
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Copyright Ó2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
are expensive and are also associated with a high rate of
complications, including infection, mechanical failure,
and dislocation. Bus et al. [4] studied 47 patients with
a LUMiC(R) prosthesis and found that infection (28%)
and dislocation (22%) were relatively common. Hipfl
et al. [12] reported that 40% patients with pedestal cups
developed complications, including infection (17%),
dislocation (15%), and aseptic loosening (6%). Al-
though autograft reconstruction might have the natural
advantage of good biocompatibility, complications are
still encountered. In one study [3] involving 13 patients
with the proximal femur used for pelvic reconstruction,
four patients underwent revision surgery as a result of
mechanical failure and infection. Four dislocations
(31%) occurred. Laffosse et al. [17]alsousedtheipsi-
lateral femur for reconstruction in 10 patients. The major
complications were dislocation (30%) and infection
(20%). The complications in our study are fairly similar
to those of other reports except for dislocation. No hip
dislocation occurred in our small group, although it was
frequent in massive allograft (8%-18%) [5,6], pelvic
prosthesis (15%-22%) [4,12], and femoral autograft
(30%-31%) [3,17]. We attribute this to the following
factors. First, we reamed the new acetabulum as close to
the original location of the acetabulum as possible to
ensure the right abduction and anteversion angle. Sec-
ond, the reconstruction of the hip capsule was performed
by using hernia mesh in six patients, which helped
maintain hip stability at the early stage and facilitated
scar tissue growing in at the late stage. Third, patients
were immobilized in bed for a long period (8 weeks)
postoperatively.
The reconstruction of pelvic bone defects after pelvic
tumor resection is difficult and no one reconstruction
option has been shown to be predictably better than
others. We report early experience using the ipsilateral
proximal femur as a method for pelvic reconstruction.
Longer followup and more patients treated using this
method are necessary to know if this approach is su-
perior to other types of reconstruction, but our early
experience suggests it may be suitable for bone defects
of both pelvic area II + III and pelvic area I + II. A high
proportion of patients who undergo this complex
procedure will experience major complications. The
short-term function appears to be similar to that of
pelvic prostheses, massive allografts, and autografts.
Although a larger study with more patients and longer
followup will be necessary to confirm the potential
benefits of this technique, we believe that this approach
might be particularly useful in young or middle-aged
patients with primary malignant or aggressive benign
tumors involving pelvic Type II and may provide sat-
isfactory reconstruction of periacetabular pelvic bone
defects.
Acknowledgments We thank Yunxia Liu MD (Department of On-
cology, Third People’s Hospital of Hangzhou) for help with chart review,
Leiming Xu MD (Department of Radiology, Second Affiliated Hospital of
Zhejiang University School of Medicine) for help with CT-guided biopsy,
and Yanbiao Fu MD (Department of Pathology, Second Affiliated Hos-
pital of Zhejiang University School of Medicine) for pathology evaluation.
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