All osseous resections were followed by anatomic reconstruction with a bone (obtained from the local nationally registered bone bank) that was similar to the one that had been resected. Pelvic allografts were sterilely procured in an operating room from organ donors by a surgical team26. The average age of the donors at the time of death was 40 ± 13 years (range, fourteen to sixty-two years; median, forty-two years). Bones were immersed in serum with rifampicin (1.2 g/L of serum) for one hour before being frozen at –80°C until use. The mean preservation time was 13 ± 12 months (range, 0.5 to thirty-eight months). No final irradiation for sterilization was performed. At the time of the surgery, the allograft was thawed for about one hour in a rifampicin solution at 37°C.
Allografts were fixed by one or preferably two molded 3.5-mm ASIF reconstruction plates (Synthes, Brussels, Belgium) in the periacetabular area and/or with one or two 6.5-mm lag screws in the sacrum and/or one screw in the pubic ramus. In thirteen patients, a cemented total hip prosthesis that included a cemented polyethylene cup and a 22.2 or 28-mm metallic head was implanted to restore the hip joint (Figs. 2-A and 2-B). In five patients, the acetabular component of the allograft matched the femoral head of the patient and the hip joint was restored without a prosthesis (Figs. 3-A and 3-B). All spared muscles were attached when possible to the pelvic allograft. Three patients were treated with traction for three weeks, as the hip was considered to be unstable at the time of surgery, and two others were treated with an anti-dislocation device for eight weeks after an episode of prosthesis dislocation. The remaining patients were not treated with immobilization postoperatively. Weight-bearing was not allowed for two months, to allow soft-tissue healing. After two months, patients were allowed to walk with two crutches and progressive loading on the operatively treated limb. Adjuvant chemotherapy, if any, was resumed at three weeks postoperatively.
Patient function was assessed according to the Musculoskeletal Tumor Society (MSTS) criteria27. Pain, functional capacity, walking distance, use of a support, gait, and emotional acceptance were each evaluated on a 5-point scale, with a maximum total score of 30 points recorded as 100%. Patients who had received two successive allografts were assigned two separate scores for function. The follow-up period was calculated from the time of surgery to the last consultation, to the time of allograft removal, or until the patient's death. Living patients were analyzed at a minimum of twenty-four months postoperatively.
Nonparametric testing was performed with the SPSS statistical package (version 12.0; SPSS, Chicago, Illinois). The Mann-Whitney U test was used to compare two unpaired subgroups of patients according a grouping variable such as the location of the resection, an age of less than twenty years or an age of twenty years or older, whether palsy had occurred, surgical revision, and union or nonunion. These subsets were compared with regard to the duration of surgery, the blood loss, the MSTS score, and the hospital stay. Relationships between two sets of parameters were analyzed with use of the Spearman rank order correlation coefficient. The level of significance was set at p < 0.05.
The duration of follow-up ranged from one to 137 months, with an average of forty-one months. Every living patient in the series was followed for a minimum of twenty-four months. The main data on the patients are listed in a table in the Appendix.
The mean duration of the complete surgical procedure (from the induction of the anesthesia until the patient was taken from the operating room) was 10 ± 2.8 hours (range, 4.5 to 16.5 hours). The average compensated blood loss during the hospital stay was 4359 ± 2800 mL (range, 1000 to 11,300 mL). The amount of blood loss correlated with the duration of the surgery (r = 0.44; p = 0.03) but not with the duration of the hospital stay, patient age, or the area of bone resection (zone II compared with not zone II). The mean hospital stay was 25 ± 18 days (range, ten to ninety-four days) and correlated strongly with patient age, with older patients having the longest stay (r = 0.61; p = 0.001), but not with the duration of the operation. Tissue culture of allograft specimens obtained at the time of the surgery were negative, except for two cases of late growth of Peptostreptococcus or Corynebacterium. Intravenous antibiotic therapy was discontinued after one week except for the two patients with positive cultures, who were treated for three weeks. A clinical infection did not develop in either of those two patients. Adjuvant chemotherapy was resumed at three weeks for fourteen patients and was delayed for three others because of skin necrosis or infection.
The surgical resection included the periacetabular area (zone II) in eighteen patients. Those patients did not differ significantly from the patients without acetabular resection with regard to age, operative time, hospital stay, or amount of blood transfused, with the numbers available (Table II). Five patients, with a mean age of 15 ± 5 years, had an osteoarticular allograft that allowed sparing of the femoral head. In thirteen other patients with a periacetabular excision (mean age, 46 ± 22 years), the hip was restored with a cemented hip prosthesis. The sacroiliac joint was resected in four patients and was replaced with an allograft and an arthrodesis, usually with fixation with two screws. In two patients, the three zones (I, II, and III) were resected and reconstructed. All except three of the resections disrupted the pelvic arch. The surgical resection was wide in nineteen patients, marginal in six, and intralesional in one.
Eight (33%) of the twenty-four patients were alive and free of disease when they were last seen, at a mean of seventy months. Thirteen patients (54%) had died of the disease, and there were three deaths not related to the malignant tumor. A local recurrence was observed in seven patients (29%), two of whom underwent hindquarter amputation.
Of the nineteen patients with a primary bone tumor, six were alive without evidence of disease at a mean of 62 ± 40 months postoperatively. In this group with primary sarcoma, a local recurrence occurred in seven patients after a mean time of 21 ± 19 months. Of the five patients with a solitary bone metastasis located in or next to zone II, two survived without evidence of disease for an average of ninety-five months. There were two deaths unrelated to the tumor and no local tumor recurrence.
Surgical Complications and Morbidity
There was one early postoperative death from a pulmonary embolism at four weeks. The morbidity rate was high (Table III). One patient had a femoral artery thrombosis diagnosed in the immediate postoperative period; this required vascular revision, which was complicated by a compartment syndrome necessitating additional surgery. Two patients had skin necrosis, and there were three deep infections. We found no relationship between infection and either blood loss or the duration of the surgery, with the numbers available.
Neurological complications and hip dislocation or subluxation were observed only in the eighteen patients with a zone-II resection (Table III). Sciatic nerve palsy occurred in six patients, who had only partial recovery. One of these patients also had a femoral nerve palsy. Patients with neurological deficits had a significantly longer duration of the operation (p = 0.022) than did those without a deficit. Hip complications were observed in five patients. Two hip prostheses dislocated. Two femoral heads gradually subluxated from an acetabulum reconstructed with an osteochondral allograft and were left untreated. One femoral fracture occurred distal to the prosthetic stem, and it was treated with a plate.
Of the twenty-four patients, eleven (46%) had a total of sixteen surgical procedures to treat a complication of the surgery and nine underwent a surgical revision related directly to the reconstruction itself. Thirteen patients (54%), with a mean age of twenty-five years at the time of the index operation, had no surgical revision; these patients were younger than the eleven patients who required revision (average age, forty-four years; p = 0.031).
Evaluation of Bone Allografts
Sixteen allografts could be evaluated radiographically for healing, as they were in patients who had been followed for at least eighteen months. An unhealed junction after that period was considered to be a nonunion21.
There were forty-three anastomotic junctions with host bone, and five of them (12%) failed to unite by eighteen months postoperatively. Two nonunions were revised with new allografts, which also failed to unite. Nonunion was not found to be significantly associated with the age of the patient, duration of the surgery, or amount of blood transfused, with the numbers available. Hardware failure was observed in two patients with a nonunion and in a third patient in the immediate postoperative period.
No resorption or lysis and no fracture of the graft were observed in this series. Seven allografts had an uneventful course for at least three years, and four of them had an uneventful course for five years. Of the five patients who had had a hip joint reconstruction with an osteoarticular allograft, two subsequently had progressive dislocation of the femoral head with wear of the acetabular roof.
The Musculoskeletal Tumor Society (MSTS) score could be determined for twenty-three patients who had a total of twenty-five allografts, as one patient had died one month postoperatively. The mean MSTS score was 21.5 ± 6 points (73% of the maximal possible score)27. The MSTS score was found to be inversely correlated with patient age (r = –0.58; p = 0.002) as well as with the duration of the operation (r = –55; p = 0.007). The eleven patients who were less than twenty years of age had an average score of 24.7 ± 7 points (82% of the maximal score) whereas the older patients had an average score of 19 ± 5 points (65% of the maximal score). This difference was significant (p = 0.016).
All except four patients were able to walk. The patients who could walk had an average MSTS score of 23 points (78% of the maximal score). Three patients needed two crutches for walking, five patients occasionally used one crutch, and two routinely used one crutch. Ten patients walked without any device, and five of them had normal function with no or only a slight limp and an unlimited walking capacity. The walking performance of the eleven patients who were younger than twenty years old was excellent; eight of the children walked without support, two of them occasionally used a crutch, and one was unable to walk.
The six patients with a reconstruction in zone I or in zones I and IV had an average MSTS score of 26 ± 3.8 points, whereas the seventeen with a reconstruction in zone II alone or in combination with one or more of the other zones had an average score of 20.4 ± 6.6 points. With the numbers available, this difference was not significant (Table II).
When excision of a pelvic tumor and reconstruction have been combined in one procedure, the reported complication rate has been high, ranging from 30% to 90% in series ranging in size from nine to ninety-six patients8,13-17,19,22-24,28,29. Carter et al.1 reported that a hindquarter amputation without reconstruction was associated with a 41% complication rate in a series of thirty-four patients. The reported durations of operations that included both pelvic resection and pelvic reconstruction have been high, ranging from five to ten hours8,10,14,22,24, with blood loss ranging from 2500 to 8300 mL depending on the extent of the reconstruction8,10,14,17,22. The data in our study are consistent with those findings.
There were no perioperative deaths in our series, and the postoperative mortality rate was low. The femoral artery thrombosis that occurred in a patient with Ewing sarcoma resulted from prolonged excessive traction during a lengthy procedure and might invoke the question of whether surgery is the best option to control a radiosensitive tumor. Studies dealing with pelvic Ewing sarcoma have had conflicting results; the impact of surgery on overall survival could not be verified in some of them30-32, whereas others have indicated that surgery combined with chemotherapy tends to offer better local control and survival than any other combination of treatments without surgery33-40. Surgery should be considered only when the tumor can be completely removed. The role of surgery for less radiosensitive tumors, such as osteosarcomas, and for nonresponsive tumors, such as chondrosarcomas, is more obvious4,5,41,42.
Neurological problems were the most frequent surgical complications, with a prevalence of 25%, and were exclusively observed in patients with a periacetabular resection (zone II). The reported rate has ranged from 3% to 30% in series ranging in size from nine to ninety-two patients7,10,13,16,28,29. Most palsies were complete and partially resolved; full recovery was not the rule in our series. According to Capanna et al.7,41, neurological complications are predominant following iliac resections with disruption of the greater sciatic notch.
Limb-sparing surgery has become accepted standard surgical treatment for primary bone sarcoma unless the lesion cannot be surgically removed in an appropriate manner. Wide resection and reconstruction remain a questionable approach for a solitary bone metastasis in zone II of the pelvis, where curettage, cementation, and the placement of a supportive ring and prosthesis have been reported to have good results43. In patients with metastatic carcinoma, the risks can outweigh the expected benefit of a wide resection. A potentially curative reconstruction appears not to be the procedure of choice in this circumstance, except for an isolated metastasis that is resistant to radiation therapy and chemotherapy43. Limb-sparing surgery exposes the patient to a tumor resection with narrower margins than are achieved with a hindquarter amputation, which also does not guarantee eradication of the local disease1,23. In studies of limb-salvage procedures in series ranging in size from thirty-five to ninety-two patients, the local recurrence rate has ranged from 28% to 35%13,15,28,41,42; the rate in our study is within that range.
There is no unanimous opinion regarding the most appropriate method of reconstruction. Periacetabular resection without reconstruction will result in pelvic instability44. Many authors8,10,45,46 have demonstrated that patients with a stable, reconstructed pelvis have better MSTS functional scores than do patients without pelvic reconstruction. Palliative surgery such as iliofemoral or ischiofemoral arthrodesis, although better than amputation, is less well accepted nowadays.
In zone II, there are several alternatives to an allograft reconstruction. The range of reconstruction techniques has been broadened by the development of new prostheses, new biomaterials9,12-14,29,47, and new surgical methods20. There are three current techniques for periacetabular reconstruction: insertion of a saddle prothesis14, use of a computer-aided-designed prosthesis to bridge the resection12,13,47, and a hip arthroplasty with cement and with or without11 the support of an autograft17,18,20 or an allograft18,23,24. The advantage of a saddle prosthesis is modularity and ease of reconstruction14. The other techniques are more complex as the reconstruction must fit the resection. The use of bone, whether autograft or allograft, allows the surgeon to implant a conventional total or bipolar prosthesis and to match a potentially greater resection than anticipated. A total hip arthroplasty with cement was preferred in our series because wear of the allograft was a potential concern with the use of a bipolar prosthesis48.
Infection is a major surgical complication of pelvic reconstruction, regardless of the method of reconstruction. Its prevalence has ranged from 0% to 37% in series ranging in size from nine to ninety-six patients8,13-17,19,22-24,28,29,46. Ozaki et al.22 and Hillmann et al.46 reported a 37% infection rate in their respective series of twenty-two and thirteen patients treated with a pelvic allograft, which would indicate that this procedure is an unacceptable choice. Such a high rate was not found by others23,24 nor by us in the present study. This discrepancy remains unclear but may be related to the procurement of the allograft. We could not confirm the finding by Hong Tan and Mankin49 that blood loss influenced the infection rate. Impregnation of the allografts with rifampicin at the time of procurement and at implantation has decreased the rate of contamination of bone allografts in our experience26. Bone has been shown to be an appropriate carrier of antibiotics that will be released from the time of implantation and for at least twenty-one days50-52.
Fracture and nonunion are concerns with the use of allograft or irradiated bone and autograft16,19,22-24. In our study, nonunion occurred in three young adult patients with a high activity demand. In two of them, the allograft was inadequately matched with the host bone, leaving a large interfragmentary gap. Cutting and adjusting a hemipelvic graft to fit the area of osseous resection was one of the most difficult steps in the reconstruction and was most challenging in zone II. Selection of a size-matched pelvic allograft remains a concern. Another difficulty is related to fixation in the ilium, which can be tenuous. We observed two nonunions in this location. Gaps and narrow surfaces at the junctions were both concerns associated with nonunion. We believe that there is a need for a computer-assisted osteotomy in tumor resection and in cutting of the bone allograft in order to achieve a better match of the allograft to the resection.
Another concern associated with bone allografts is the potential transmission of viral diseases53,54. Procedures have been designed to ensure the supply of safe tissues. These include guidelines for donor selection, tissue quarantine, and tissue processing. The risk of transmitting a communicable disease remains remote with the implementation of quality systems in tissue banks and specific procedures for safety such as back-screening and nucleic acid testing of organ and tissue donors.
We advocate the use of a pelvic allograft instead of bones from another skeletal location. This allows true anatomical restoration of the complex architecture of the pelvis and leaves open various options for hip preservation, particularly in children.
Anatomical reconstruction following a pelvic resection provides the opportunity for much better function than does palliative reconstruction. The range of function as calculated as the percentage of the maximum MSTS score (normal function) ranged from 55% to 70% in series ranging from thirteen to thirty-nine patients9,13,23,24. In series of patients in whom the pelvis was reconstructed with either an allograft or a prosthesis16,46, the allografts compared favorably with the prostheses in adults as well children. We reported an average MSTS score of 73%, confirming the possibility of obtaining an anatomically and biomechanically sound reconstruction with an allograft. More than half of our twenty-four patients walked without crutches or only occasionally used one crutch. In our series, as in a previous one16, children and teenagers performed substantially better than adults, with an average score of 82% compared with 65%. Ten of the eleven children walked without support or with only occasional use of a crutch. Whether this was due to their age or to a lesser extent of revision surgery could not be determined.
The rate of complications of limb-sparing pelvic resection is high. Today, limb-sparing surgery with reconstruction is preferred to amputation when possible13,23,28,41, but it should usually be reserved for primary sarcoma. We believe that, when such reconstruction is anticipated, a pelvic allograft should be considered, especially in young patients, in whom very acceptable function can be expected.
A table showing clinical details regarding all twenty-four patients is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ▪
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Cliniques Universitaires St.-Luc, Brussels, Belgium
1. , Eastwood DM, Grimer RJ, Sneath RS. Hindquarter amputation for tumours of the musculoskeletal system. J Bone Joint Surg Br. 1990;72: 490-3.
2. , Doppelt S, Tomford W. Clinical experience with allograft implantation. The first ten years. Clin Orthop Relat Res. 1983;174: 69-86.
3. . Local resection of malignant lesions of the hip and pelvis. J Bone Joint Surg Am. 1966;48: 991-1007.
4. , Hjelmstedt A. Limb-saving radical resection of chondrosarcoma of the pelvis. J Bone Joint Surg Am. 1976;58: 568-70.
5. , Dunham WK. Resection and reconstruction for primary neoplasms involving the innominate bone. J Bone Joint Surg Am. 1978;60: 731-46.
6. . Partial or complete resection of the hemipelvis. An alternative to hindquarter amputation for periacetabular chondrosarcoma of the pelvis. J Bone Joint Surg Am. 1978;60: 719-30.
7. , van Horn JR, Guernelli N, Briccoli A, Ruggieri P, Biagini R, Bettelli G, Campanacci M. Complications of pelvic resections. Arch Orthop Trauma Surg. 1987;106: 71-7. Erratum in: Arch Orthop Trauma Surg. 1987;106:262.
8. , Sim FH. Salvage of the limb in the treatment of malignant pelvic tumors. J Bone Joint Surg Am. 1989;71: 481-94.
9. , Schulte M, Mutschler WE. Surgical treatment of pelvic sarcomas: oncologic and functional outcome. Clin Orthop Relat Res. 2001;390: 190-205.
10. , Ek ET, Choong PF. Research: Is resection of tumours involving pelvic ring justified? A review of 49 consecutive cases. Int Semin Surg Oncol. 2005;2: 9.
11. . Reconstruction of the pelvic ring following tumor resection. J Bone Joint Surg Am. 1978;60; 747-51.
12. , Rechl H, Hipp E. Pelvic osteosarcoma. Resection, reconstruction, local control, and survival statistics. Clin Orthop Relat Res. 1991;270: 149-58.
13. , Grimer RJ, Cannon SR, Carter SR, Sneath RS. Reconstruction of the hemipelvis after the excision of malignant tumours. Complications and functional outcome of prostheses. J Bone Joint Surg Br. 1997;79: 773-9.
14. , Buch R, Mathews J, Li W, Malawer MM. Reconstruction using the saddle prosthesis following excision of primary and metastatic periacetabular tumors. Clin Orthop Relat Res. 1995;314: 203-13.
15. , Schulte M, Maier B, Mutschler WE. Megaprosthetic replacement of the pelvis: function in 17 cases. Acta Orthop Scand. 1999;70: 348-52.
16. , Dominkus M, Krepler P, Dorotka R, Lang S, Windhager R, Kotz R. Reconstruction of the pelvis after tumor resection in children and adolescents. Clin Orthop Relat Res. 2002;402: 220-35.
17. Jr, O'Donnell RJ, Johnston JO. Reconstruction of the pelvis after resection of tumors about the acetabulum. Clin Orthop Relat Res. 2003;409: 209-17.
18. . The use of hemipelvic allografts or autoclaved grafts for reconstruction after wide resections of malignant tumors of the pelvis. J Bone Joint Surg Am. 1992;74: 331-41.
19. , Uyttendaele D, Poffyn B, Verdonk R, Verstraete L. Extracorporeally irradiated autografts in pelvic reconstruction after malignant tumour resection. Int Orthop. 2002;26: 174-8.
20. Resection-reconstruction des tumeurs de l'os iliaque. In: Duparc J, editor. Conferences d'enseignement. Paris: Masson; 1997. p 91-104.
21. , de Nayer P, Allington N, Munting E, Coutelier L, Vincent A. Massive bone allografts in large skeletal defects after tumor surgery: a clinical and microradiographic evaluation. Arch Orthop Trauma Surg. 1988;107: 31-41.
22. , Hillmann A, Bettin D, Wuisman P, Winkelmann W. High complication rates with pelvic allografts. Experience of 22 sarcoma resections. Acta Orthop Scand. 1996;67: 333-8.
23. , Davis AM, Wunder JS, Buconjic T, McGoveran B, Gross AE. Allograft reconstruction of the acetabulum after resection of stage-IIB sarcoma. Intermediate-term results. J Bone Joint Surg Am. 1997;79: 1663-74.
24. , Lambotte JC, Thomazeau H. Long-term results of hemipelvis reconstruction with allografts. Clin Orthop Relat Res. 2001;388: 178-86.
25. , Spanier SS, Goodman MA. Current Concepts Review. The surgical staging of musculoskeletal sarcoma. J Bone Joint Surg Am. 1980;62: 1027-30.
26. Bone banking in orthopaedic surgery. In: Gallinaro P, Lemaire R, editors. Surgical techniques in orthopaedics and traumatology. Paris: Elsevier; 2000. p 55-61.
27. , Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res. 1993;286: 241-6.
28. , Temple HT, O'Keefe RJ, Scarborough MT, Mankin HJ, Gebhardt MC. Role of surgical resection in pelvic Ewing's sarcoma. J Clin Oncol. 1995;13: 2336-41.
29. , Jurgens H, Sauer R, Pape H, Paulussen M, Winkelmann W, Rube C. Radiation therapy in Ewing's sarcoma: an update of the CESS 86 trial. Int J Radiat Oncol Biol Phys. 1995;32: 919-30.
30. , Krailo MD, Tarbell NJ, Link MP, Fryer CJ, Pritchard DJ, Gebhardt MC, Dickman PS, Perlman EJ, Meyers PA, Donaldson SS, Moore S, Rausen AR, Vietti TJ, Miser JS. Addition of ifosfamide and etoposide to standard chemotherapy for Ewing's sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med. 2003;348: 694-701.
31. , Eckardt JT, Eilber FR, Rosen G, Forscher CA, Dorey FJ, Kelly CM, al-Shaikh R. Surgical indications for Ewing's sarcoma of the pelvis. Cancer. 1995;76: 1388-97.
32. , Mascard E, Gomez F, Habrand JL, Alapetite C, Oberlin O, Moncho V, Hoffstetter S. Nonmetastatic pelvic Ewing sarcoma: report of the French society of pediatric oncology. Med Pediatr Oncol. 1999;33: 444-9.
33. , Rougraff B, McGrath BE, Sizinski J, Davis M, Papandonatos G, Green D, Szarzanowicz T, Mindell ER. Ewing's sarcoma of the pelvis. Long-term survival and functional outcome. Clin Orthop Relat Res. 2000;373: 193-201.
34. , Frassica DA, Pritchard DJ, Schomberg PJ, Wold LE, Sim FH. Ewing sarcoma of the pelvis. Clinicopathological features and treatment. J Bone Joint Surg Am. 1993;75: 1457-65.
35. , Windhager R, Lang S, Heinzl H, Krepler P, Mittermayer F, Dominkus M, Zoubek A, Kotz R. The role of surgery and resection margins in the treatment of Ewing's sarcoma. Clin Orthop Relat Res. 2001;392: 394-9.
36. . Current concepts in the treatment of Ewing's sarcoma. Expert Rev Anticancer Ther. 2002;2: 687-94.
37. , Hoffmann C, Gosheger G, Leidinger B, Jurgens H, Winkelmann W. Ewing's sarcoma of the pelvis: combined surgery and radiotherapy treatment. J Surg Oncol. 2003;83: 154-60.
38. Jr, Wexler LH, Marcus RB, Fairclough D, Weaver-McClure L, White M, Mao L, Delaney TF, Pratt CB, Horowitz ME, Kun LE. Second malignancies after Ewing's sarcoma: radiation dose-dependency of secondary sarcomas. J Clin Oncol. 1996;14: 2818-25.
39. , Flege S, Kevric M, Lindner N, Maas R, Delling G, Schwarz R, von Hochstetter AR, Salzer-Kuntschik M, Berdel WE, Jürgens H, Exner GU, Reichardt P, Mayer-Steinacker R, Ewerbeck V, Kotz R, Winkelmann W, Bielack SS. Osteosarcoma of the pelvis: experience of the Cooperative Osteosarcoma Study Group. J Clin Oncol. 2003;21: 334-41.
40. , Giacomini S, Gozzi E, Ferrari S, Sangiorgi L, Tienghi A, DeGroot H, Bertoni F, Bacchini P, Bacci G, Mercuri M. Osteosarcoma of the pelvis. Eur J Surg Oncol. 2004;30: 332-40.
41. , Capanna R. Pelvic resections: the Rizzoli Institute experience. Orthop Clin North Am. 1991;22: 65-86.
42. , Dürr HR, Wegener B, Pellengahr C, Refior HJ, Jansson V. Internal hemipelvectomy and reconstruction with a megaprosthesis. Int Orthop. 2002;26: 76-9.
43. . Controversies in the surgical management of skeletal metastases. J Bone Joint Surg Br. 2005;87: 608-17.
44. , Bell RS, Griffin AM, Wunder JS. Instability after major tumor resection: prevention and treatment. Orthop Clin North Am. 2001;32: 697-710, ix-x.
45. , Hoffmann C, Hillmann A, Gosheger G, Lindner N, Winkelmann W. Implantation of hemipelvic prosthesis after resection of sarcoma. Clin Orthop Relat Res. 2002;396: 197-205.
46. , Hoffmann C, Gosheger G, Rodl R, Winkelmann W, Ozaki T. Tumors of the pelvis: complications after reconstruction. Arch Orthop Trauma Surg. 2003;123: 340-4.
47. , Myoui A, Araki N, Yoshikawa H, Ueda T, Aoki Y. Prosthetic reconstruction for periacetabular malignant tumors. Clin Orthop Relat Res. 1996;326: 238-45.
48. , Albisinni U, Zavatta M, Gozzi E, Giacomini S, Mercuri M. Long-term roentgenographic evaluation of proximal femur prosthesis after tumor resection. Chir Organi Mov. 2004;89: 191-203.
49. , Mankin HJ. Blood transfusion and bone allografts. Effect on infection and outcome. Clin Orthop Relat Res. 1997;340: 207-14.
50. , Persen L, Loseth K, Bergh K. Adsorption and release of antibiotics from morselized cancellous bone. In vitro studies of 8 antibiotics. Acta Orthop Scand. 1999;70: 298-304.
51. , Persen L, Loseth K, Benum P, Bergh K. Cancellous bone as an antibiotic carrier. Acta Orthop Scand. 2000;71: 80-4.
52. , Janata O, Berger C, Wein W, Georgopoulos A. In vitro release of vancomycin and tobramycin from impregnated human and bovine bone grafts. J Antimicrob Chemother. 2000;46: 423-8.
53. Tissue allografts and health risks. Acta Orthop Belg. 1994;60 Suppl 1: 62-7.
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54. . Transmission of disease through transplantation of musculoskeletal allografts. J Bone Joint Surg Am. 1995;77: 1742-54.