Biomechanical analysis and effectiveness evaluation of zone Ⅰ+Ⅱ+Ⅲ reconstruction of hemipelvis with rod-screw prosthesis_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

DANG Jingyi , ZHANG Zhao , MI Zhenzhou , CHENG Debin , FU Jun , LIU Dong ,  FAN Hongbin

Department of Orthopaedics, Xijing Hospital, Air Force Medical University, Xi’an Shaanxi, 710032, P. R. China;

Corresponding author：

FAN Hongbin, Email: fanhb@fmmu.edu.cn

Keywords：

Pelvic reconstruction; rod-screw prosthesis; finite element analysis; effectiveness

DOI：

10.7507/1002-1892.202110018

Video：

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Objective To analyze the biomechanical properties of the rod-screw prosthesis based on a pelvic three-dimensional finite element model including muscle and ligament, and evaluate the effectiveness of zoneⅠ+Ⅱ+Ⅲ reconstruction of hemipelvis with rod-screw prosthesis in combination with clinical applications. Methods A total of 21 patients who underwent hemipelvic tumor resection (zoneⅠ+Ⅱ+Ⅲ) and rod-screw prosthesis reconstruction between January 2015 and December 2020 were selected as the research subjects. Among them, there were 11 males and 10 females; the age ranged from 16 to 64 years, with an average age of 39.2 years. There were 9 cases of chondrosarcoma, 7 cases of osteosarcoma, 3 cases of Ewing sarcoma, and 2 cases of undifferentiated pleomorphic sarcoma. According to the Musculoskeletal Tumor Society Score (MSTS) staging, there were 19 cases of stage ⅡB and 2 cases of stage Ⅲ. Preoperative Harris Hip Score (HHS) and MSTS score were 54.4±3.1 and 14.1±2.0, respectively. Intraoperative 15 cases underwent extensive resection, 5 cases underwent marginal resection, and 1 case underwent intralesional resection. The CT image of 1 patient after reconstruction was used to establish a three-dimensional solid model of the pelvis via Mimics23Suite and 3-matic softwares. At the same time, a mirror operation was used to obtain a normal pelvis model, then the two solid models were imported into the finite element analysis software Workbench 2020R1 to establish three-dimensional finite element models, and the biomechanical properties of the standing position were analyzed. The operation time, intraoperative blood loss, and operation-related complications were recorded, and the postoperative evaluation was carried out with HHS and MSTS scores. Finally, the local recurrence and metastasis were reviewed. Results Finite element analysis showed that the peak stress of the reconstructed pelvis appeared at the fixed S_{1, 2} rod-screw connections; the peak stress without muscles was higher than that after muscle construction, but much smaller than the yield strength of titanium alloy. The operation time was 250-370 minutes, with an average of 297 minutes; the amount of intraoperative blood loss was 3 200-5 500 mL, with an average of 4 009 mL. All patients were followed up 8-72 months, with an average of 42 months. There were 7 cases of pulmonary metastasis, of which 2 cases were preoperative metastasis; 5 cases died, 16 cases survived, and the 5-year survival rate was 72.1%. There were 3 cases of local recurrence, all of whom did not achieve extensive resection during operation. The function of the affected limbs significantly improved, and the walking function was restored. The HHS and MSTS scores were 75.2±3.0 and 20.4±2.0 at last follow-up, respectively, and the differences were significant when compared with those before operation (t=22.205, P<0.001; t=11.915, P<0.001). During follow-up, 2 cases of delayed incision healing, 2 cases of deep infection, 1 case of screw loosening, and 1 case of prosthesis dislocation occurred, and no other complication such as prosthesis or screw fracture occurred. Conclusion The stress and deformation distribution of the reconstructed pelvis are basically the same as normal pelvis. The rod-screw prosthesis is an effective reconstruction method for pelvic malignant tumors.

Citation： DANG Jingyi, ZHANG Zhao, MI Zhenzhou, CHENG Debin, FU Jun, LIU Dong, FAN Hongbin. Biomechanical analysis and effectiveness evaluation of zone Ⅰ+Ⅱ+Ⅲ reconstruction of hemipelvis with rod-screw prosthesis. Chinese Journal of Reparative and Reconstructive Surgery, 2022, 36(4): 431-438. doi: 10.7507/1002-1892.202110018 Copy

1.	Wang B, Sun P, Yao H, et al. Modular hemipelvic endoprosthesis with a sacral hook: a finite element study. J Orthop Surg Res, 2019, 14(1): 309. doi: 10.1186/s13018-019-1338-z.
2.	Wang J, Min L, Lu M, et al. What are the complications of three-dimensionally printed, custom-made, integrative hemipelvic endoprostheses in patients with primary malignancies involving the acetabulum, and what is the function of these patients? Clin Orthop Relat Res, 2020, 478(11): 2487-2501.
3.	Yu Z, Zhang W, Fang X, et al. Pelvic reconstruction with a novel three-dimensional-printed, multimodality imaging based endoprosthesis following Enneking typeⅠ+ Ⅳ resection. Front Oncol, 2021, 11: 629582. doi: 10.3389/fonc.2021.629582.
4.	Fujiwara T, Ogura K, Christ A, et al. Periacetabular reconstruction following limb-salvage surgery for pelvic sarcomas. J Bone Oncol, 2021, 31: 100396. doi: 10.1016/j.jbo.2021.100396.
5.	Ogura K, Susa M, Morioka H, et al. Reconstruction using a constrained-type hip tumor prosthesis after resection of malignant periacetabular tumors: A study by the Japanese Musculoskeletal Oncology Group (JMOG). J Surg Oncol, 2018, 117(7): 1455-1463.
6.	Maslov L, Borovkov A, Maslova I, et al. Finite element analysis of customized acetabular implant and bone after pelvic tumour resection throughout the gait cycle. Materials (Basel), 2021, 14(22): 7066. doi: 10.3390/ma14227066.
7.	Errani C, Alfaro PA, Ponz V, et al. Does the addition of a vascularized fibula improve the results of a massive bone allograft alone for intercalary femur reconstruction of malignant bone tumors in children? Clin Orthop Relat Res, 2021, 479(6): 1296-1308.
8.	Xie XJ, Cao SL, Tong K, et al. Three-dimensional finite element analysis with different internal fixation methods through the anterior approach. World J Clin Cases, 2021, 9(8): 1814-1826.
9.	Zheng J, Feng X, Xiang J, et al. S₂-alar-iliac screw and S₁ pedicle screw fixation for the treatment of non-osteoporotic sacral fractures: a finite element study. J Orthop Surg Res, 2021, 16(1): 651. doi: 10.1186/s13018-021-02805-8.
10.	Song K, Pascual-Garrido C, Clohisy JC, et al. Acetabular edge loading during gait is elevated by the anatomical deformities of hip dysplasia. Front Sports Act Living, 2021, 3: 687419. doi: 10.3389/fspor.2021.687419.
11.	Ramezani M, Klima S, de la Herverie PLC, et al. In silico pelvis and sacroiliac joint motion: refining a model of the human osteoligamentous pelvis for assessing physiological load deformation using an inverted validation approach. Biomed Res Int, 2019, 2019: 3973170. doi: 10.1155/2019/3973170.
12.	López Gualdrón CI, Bravo Ibarra ER, Murillo Bohórquez AP, et al. Present and future for technologies to develop patient-specific medical devices: a systematic review approach. Med Devices (Auckl), 2019, 12: 253-273.
13.	Zhang Y, Tang X, Ji T, et al. Is a modular pedicle-hemipelvic endoprosthesis durable at short term in patients undergoing Enneking typeⅠ+ Ⅱ tumor resections with or without sacroiliac involvement? Clin Orthop Relat Res, 2018, 476(9): 1751-1761.
14.	Childers WL, Takahashi KZ. Increasing prosthetic foot energy return affects whole-body mechanics during walking on level ground and slopes. Sci Rep, 2018, 8(1): 5354. doi: 10.1038/s41598-018-23705-8.
15.	Shan T, Anlin L, Mingming Y, et al. Anterior supra-acetabular external fixation for tile C₁ pelvic fractures: a digital anatomical study and a finite element analysis. Eur J Trauma Emerg Surg, 2021, 47(6): 1679-1686.
16.	Jud L, Andronic O, Vlachopoulos L, et al. Mal-angulation of femoral rotational osteotomies causes more postoperative sagittal mechanical leg axis deviation in supracondylar than in subtrochanteric procedures. J Exp Orthop, 2020, 7(1): 46. doi: 10.1186/s40634-020-00262-6.
17.	Afonso PD, Weber MA, Isaac A, et al. Hip and pelvis bone tumors: Can you make it simple? Semin Musculoskelet Radiol, 2019, 23(3): e37-e57.
18.	Phillips AT, Pankaj P, Howie CR, et al. 3D non-linear analysis of the acetabular construct following impaction grafting. Comput Methods Biomech Biomed Engin, 2006, 9(3): 125-133.
19.	Wang H, Tang X, Ji T, et al. Risk factors for early dislocation of the hip after periacetabular tumour resection and endoprosthetic reconstruction of the hemipelvis. Bone Joint J, 2021, 103-B(2): 382-390.
20.	Ghosh R, Mukherjee K, Gupta S. Bone remodelling around uncemented metallic and ceramic acetabular components. Proc Inst Mech Eng H, 2013, 227(5): 490-502.
21.	Marew T, Birhanu G. Three dimensional printed nanostructure biomaterials for bone tissue engineering. Regen Ther, 2021, 18: 102-111.
22.	Markovitz MA, Lu S, Viswanadhan NA. Role of 3D printing and modeling to aid in neuroradiology education for medical trainees. Fed Pract, 2021, 38(6): 256-260.
23.	Kitamura K, Fujii M, Iwamoto M, et al. Effect of coronal plane acetabular correction on joint contact pressure in periacetabular osteotomy: a finite-element analysis. BMC Musculoskelet Disord, 2022, 23(1): 48. doi: 10.1186/s12891-022-05005-5.
24.	Ji T, Guo W, Yang RL, et al. Modular hemipelvic endoprosthesis reconstruction—experience in 100 patients with mid-term follow-up results. Eur J Surg Oncol, 2013, 39(1): 53-60.
25.	Iqbal T, Wang L, Li D, et al. A general multi-objective topology optimization methodology developed for customized design of pelvic prostheses. Med Eng Phys, 2019, 69: 8-16.
26.	Henyš P, Kuchař M, Hájek P, et al. Mechanical metric for skeletal biomechanics derived from spectral analysis of stiffness matrix. Sci Rep, 2021, 11(1): 15690. doi: 10.1038/s41598-021-94998-5.
27.	Xie P, Deng Y, Tan J, et al. The effect of rotational degree and routine activity on the risk of collapse in transtrochanteric rotational osteotomy for osteonecrosis of the femoral head-a finite element analysis. Med Biol Eng Comput, 2020, 58(4): 805-814.
28.	Wang J, Min L, Lu M, et al. Three-dimensional-printed custom-made hemipelvic endoprosthesis for the revision of the aseptic loosening and fracture of modular hemipelvic endoprosthesis: a pilot study. BMC Surg, 2021, 21(1): 262. doi: 10.1186/s12893-021-01257-5.
29.	Bus MP, Boerhout EJ, Bramer JA, et al. Clinical outcome of pedestal cup endoprosthetic reconstruction after resection of a peri-acetabular tumour. Bone Joint J, 2014, 96-B(12): 1706-1712.
30.	Guo W. Limb-salvage treatment of malignant pelvic bone tumor in China for past 20 years. Chin Med J (Engl), 2019, 132(24): 2994-2997.
31.	De Paolis M, Sambri A, Zucchini R, et al. Custom-made 3D-printed prosthesis in periacetabular resections through a novel ileo-adductor approach. Orthopedics, 2022: 1-5.
32.	Chen X, Xu L, Wang Y, et al. Image-guided installation of 3D-printed patient-specific implant and its application in pelvic tumor resection and reconstruction surgery. Comput Methods Programs Biomed, 2016, 125: 66-78.
33.	蔡青, 党竞医, 付军, 等. 导板联合导航技术用于骨盆肿瘤切除术后髋臼重建定位的研究. 实用骨科杂志, 2021, 27(08): 684-688.

1. Wang B, Sun P, Yao H, et al. Modular hemipelvic endoprosthesis with a sacral hook: a finite element study. J Orthop Surg Res, 2019, 14(1): 309. doi: 10.1186/s13018-019-1338-z.
2. Wang J, Min L, Lu M, et al. What are the complications of three-dimensionally printed, custom-made, integrative hemipelvic endoprostheses in patients with primary malignancies involving the acetabulum, and what is the function of these patients? Clin Orthop Relat Res, 2020, 478(11): 2487-2501.
3. Yu Z, Zhang W, Fang X, et al. Pelvic reconstruction with a novel three-dimensional-printed, multimodality imaging based endoprosthesis following Enneking typeⅠ+ Ⅳ resection. Front Oncol, 2021, 11: 629582. doi: 10.3389/fonc.2021.629582.
4. Fujiwara T, Ogura K, Christ A, et al. Periacetabular reconstruction following limb-salvage surgery for pelvic sarcomas. J Bone Oncol, 2021, 31: 100396. doi: 10.1016/j.jbo.2021.100396.
5. Ogura K, Susa M, Morioka H, et al. Reconstruction using a constrained-type hip tumor prosthesis after resection of malignant periacetabular tumors: A study by the Japanese Musculoskeletal Oncology Group (JMOG). J Surg Oncol, 2018, 117(7): 1455-1463.
6. Maslov L, Borovkov A, Maslova I, et al. Finite element analysis of customized acetabular implant and bone after pelvic tumour resection throughout the gait cycle. Materials (Basel), 2021, 14(22): 7066. doi: 10.3390/ma14227066.
7. Errani C, Alfaro PA, Ponz V, et al. Does the addition of a vascularized fibula improve the results of a massive bone allograft alone for intercalary femur reconstruction of malignant bone tumors in children? Clin Orthop Relat Res, 2021, 479(6): 1296-1308.
8. Xie XJ, Cao SL, Tong K, et al. Three-dimensional finite element analysis with different internal fixation methods through the anterior approach. World J Clin Cases, 2021, 9(8): 1814-1826.
9. Zheng J, Feng X, Xiang J, et al. S₂-alar-iliac screw and S₁ pedicle screw fixation for the treatment of non-osteoporotic sacral fractures: a finite element study. J Orthop Surg Res, 2021, 16(1): 651. doi: 10.1186/s13018-021-02805-8.
10. Song K, Pascual-Garrido C, Clohisy JC, et al. Acetabular edge loading during gait is elevated by the anatomical deformities of hip dysplasia. Front Sports Act Living, 2021, 3: 687419. doi: 10.3389/fspor.2021.687419.
11. Ramezani M, Klima S, de la Herverie PLC, et al. In silico pelvis and sacroiliac joint motion: refining a model of the human osteoligamentous pelvis for assessing physiological load deformation using an inverted validation approach. Biomed Res Int, 2019, 2019: 3973170. doi: 10.1155/2019/3973170.
12. López Gualdrón CI, Bravo Ibarra ER, Murillo Bohórquez AP, et al. Present and future for technologies to develop patient-specific medical devices: a systematic review approach. Med Devices (Auckl), 2019, 12: 253-273.
13. Zhang Y, Tang X, Ji T, et al. Is a modular pedicle-hemipelvic endoprosthesis durable at short term in patients undergoing Enneking typeⅠ+ Ⅱ tumor resections with or without sacroiliac involvement? Clin Orthop Relat Res, 2018, 476(9): 1751-1761.
14. Childers WL, Takahashi KZ. Increasing prosthetic foot energy return affects whole-body mechanics during walking on level ground and slopes. Sci Rep, 2018, 8(1): 5354. doi: 10.1038/s41598-018-23705-8.
15. Shan T, Anlin L, Mingming Y, et al. Anterior supra-acetabular external fixation for tile C₁ pelvic fractures: a digital anatomical study and a finite element analysis. Eur J Trauma Emerg Surg, 2021, 47(6): 1679-1686.
16. Jud L, Andronic O, Vlachopoulos L, et al. Mal-angulation of femoral rotational osteotomies causes more postoperative sagittal mechanical leg axis deviation in supracondylar than in subtrochanteric procedures. J Exp Orthop, 2020, 7(1): 46. doi: 10.1186/s40634-020-00262-6.
17. Afonso PD, Weber MA, Isaac A, et al. Hip and pelvis bone tumors: Can you make it simple? Semin Musculoskelet Radiol, 2019, 23(3): e37-e57.
18. Phillips AT, Pankaj P, Howie CR, et al. 3D non-linear analysis of the acetabular construct following impaction grafting. Comput Methods Biomech Biomed Engin, 2006, 9(3): 125-133.
19. Wang H, Tang X, Ji T, et al. Risk factors for early dislocation of the hip after periacetabular tumour resection and endoprosthetic reconstruction of the hemipelvis. Bone Joint J, 2021, 103-B(2): 382-390.
20. Ghosh R, Mukherjee K, Gupta S. Bone remodelling around uncemented metallic and ceramic acetabular components. Proc Inst Mech Eng H, 2013, 227(5): 490-502.
21. Marew T, Birhanu G. Three dimensional printed nanostructure biomaterials for bone tissue engineering. Regen Ther, 2021, 18: 102-111.
22. Markovitz MA, Lu S, Viswanadhan NA. Role of 3D printing and modeling to aid in neuroradiology education for medical trainees. Fed Pract, 2021, 38(6): 256-260.
23. Kitamura K, Fujii M, Iwamoto M, et al. Effect of coronal plane acetabular correction on joint contact pressure in periacetabular osteotomy: a finite-element analysis. BMC Musculoskelet Disord, 2022, 23(1): 48. doi: 10.1186/s12891-022-05005-5.
24. Ji T, Guo W, Yang RL, et al. Modular hemipelvic endoprosthesis reconstruction—experience in 100 patients with mid-term follow-up results. Eur J Surg Oncol, 2013, 39(1): 53-60.
25. Iqbal T, Wang L, Li D, et al. A general multi-objective topology optimization methodology developed for customized design of pelvic prostheses. Med Eng Phys, 2019, 69: 8-16.
26. Henyš P, Kuchař M, Hájek P, et al. Mechanical metric for skeletal biomechanics derived from spectral analysis of stiffness matrix. Sci Rep, 2021, 11(1): 15690. doi: 10.1038/s41598-021-94998-5.
27. Xie P, Deng Y, Tan J, et al. The effect of rotational degree and routine activity on the risk of collapse in transtrochanteric rotational osteotomy for osteonecrosis of the femoral head-a finite element analysis. Med Biol Eng Comput, 2020, 58(4): 805-814.
28. Wang J, Min L, Lu M, et al. Three-dimensional-printed custom-made hemipelvic endoprosthesis for the revision of the aseptic loosening and fracture of modular hemipelvic endoprosthesis: a pilot study. BMC Surg, 2021, 21(1): 262. doi: 10.1186/s12893-021-01257-5.
29. Bus MP, Boerhout EJ, Bramer JA, et al. Clinical outcome of pedestal cup endoprosthetic reconstruction after resection of a peri-acetabular tumour. Bone Joint J, 2014, 96-B(12): 1706-1712.
30. Guo W. Limb-salvage treatment of malignant pelvic bone tumor in China for past 20 years. Chin Med J (Engl), 2019, 132(24): 2994-2997.
31. De Paolis M, Sambri A, Zucchini R, et al. Custom-made 3D-printed prosthesis in periacetabular resections through a novel ileo-adductor approach. Orthopedics, 2022: 1-5.
32. Chen X, Xu L, Wang Y, et al. Image-guided installation of 3D-printed patient-specific implant and its application in pelvic tumor resection and reconstruction surgery. Comput Methods Programs Biomed, 2016, 125: 66-78.
33. 蔡青, 党竞医, 付军, 等. 导板联合导航技术用于骨盆肿瘤切除术后髋臼重建定位的研究. 实用骨科杂志, 2021, 27(08): 684-688.

Chinese Journal of Reparative and Reconstructive Surgery

Biomechanical analysis and effectiveness evaluation of zone Ⅰ+Ⅱ+Ⅲ reconstruction of hemipelvis with rod-screw prosthesis

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