Functional Evaluation of Flail Hip Joint after Periacetabular ...

MASATSUGU TAKAMI, et al.
constrained total hip arthroplasty [3J, use of saddle prosthesis [4J, allografting [5J ,
and covering with soft tissue only (flail hip) [6J, have been applied. We have been
performing a non-reconstructive procedure, referred to as flail hip joint. In this
report, we present our finding that relatively good function of operated legs can be
obtained with the flail hip joint as well as with a variety of methods of reconstruc­
tion.
Subjects
Subjects and Methods
The subjects were 5 patients who had primary bone tumors of the pelvis and who
had undergone pelvic resection including the acetabulum as limbsparing surgery. By
classification of resection type [7J by the original site of tumor, two patients were
classified as Type II/Ill, one as Type II II, one as Type II, and one as Type l/II/Ill
(Table 1). The period of postoperative follow-up ranged from 1 year and 2 months
to 8 years and 2 months, with an average of 3 years and 10 months. Case 1, who
had local recurrence, and Case 3, who had pulmonary metastasis at the time of the
first examination, have died. The remaining 3 patients have thusfar remained
continuously disease-free.
Methods
During the follow-up period, each patient was questioned concerning degree of
pain, use of a cane or crutches, walking ability and emotional acceptance. On
physical examination, leg-length discrepancy, range of hip motion and muscle power
were measured. X-P films were taken at neutral standing position, standing on the
operated leg and on the uninvolved leg. The function of the operated leg was
evaluated using the method of Enneking [8J.
Leg-length discrepancy
Results
The range of leg-length discrepancy was 4-7 em. The discrepancy after Type
IIII/Ill and Type IIII resections was large, and averaged 7 em (Table 1).
Postoperative wound-healing time
A range of 2.5-11 weeks was required for wound healing. In Cases 1-4, primary
healing was observed, but in Case 5, deep wound infection occurred and continuous
irrigation was continued for about one month. Since this patient had preoperative
radiotherapy (61 Gy), this treatment appeared to exert bad influence on wound
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Eunctional Evaluation of Flail Hip Joint
healing. Not including this case, the mean wound-healing time for the remaining 4
patients was 4.9 weeks.
Radiographic findings
Of the 3 patients classified as Type II/Ill or II, who had an iliac wing left in
place, two patients developed a new hip joint roof evolved from the posterior surface
of the remaining iliac wing (Cases 2 and 3). In the other patient, the head of femur
moved to the front of sciatic notch and weight bearing appeared to be between the
upper surface of the femoral neck and iliac wing (Case 5). Of the 2 patients who
were Type I/II or I/II/III, attachment of the femoral head to the lateral side of the
sacrum was found in one (Case 1), and weight-bearing by soft tissues only was found
in the other (Case 4).
Functional evaluation (Table 2)
Using the revised method of functional evaluation for legs, SlX items i.e., pam,
function, emotional acceptance, supports, walking ability and gait, were each numer­
ically scored as 1, 3 or 5 points. Scores of 2 or 4 points can also be assigned based
on the judgement of the examiner. The function of each patient was evaluated as
the rating in percentage the expected normal functional score for the patient [8J.
Complaints of pain were rare. Regarding function, minor disability was
observed. In evaluation of emotional acceptance, every patient was found to be
satisfied (3 points) or better. Two patients did not require supports, and 3 patients
used crutches or a cane. Various types of disorders were found in walking ability
and gait. In percentage rating, 2 patients exhibited good function of the operated
leg, with more than 80% (93% and 87%), 1 patient had a rating of 70% and 2
patients exhibited about half of normal function, with ratings of 57 % and 53 %.
These ratings were compared with radiographic findings. Cases 2 and 5, who ex­
hibited good function of the operated leg, had a thick portion of the supraacetabular
pelvic neck left in place. Among Cases 1, 3 and 4, who exhibited slightly inferior
function of the operated leg, Case 1 had undergone hemiresection of the pelvis, Case 4
had undergone total resection of the ilium and Case 3 had undergone left iliac ala
but with a thin portion only left in place.
Case review
Case 1: 26-year-old woman
From about October 1975, pain in the left inguinal region and limping developed.
After open biopsy, the left superior pubic ramus was resected, but local recurrence
occurred. In October 1977, resection of the left half of the pelvis was performed.
At 2 years and 4 months after operation, a radiograph was obtained with the patient
standing on the operated leg, and revealed marked sacrum tilt suggestive of partial
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MASATSUGU TAKAMI, et al.
weight-bearing from the sacrum to the femoral head (Fig. 1 a, b). Standing on the
operated leg alone was possible for about 1 minute. Using a pair of clutches, the
patient could walk with almost the same speed as a normal person does. She subseq
uently died from local recurrence in the sacral region.
Case 2: 29-year-old man
Cl-a)
Cl-b)
Figure la: Chondrosarcoma of left superior pubic ramus
Ib: Radiograph after excision of left half of the pelvis taken with patient
standing on the operated side, revealing marked sacral tilt and
suggestive of partial weight-bearing from sacrum to femoral head.
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Eunctional Evaluation of Flail Hip Joint
From about February 1982, the patient experienced pain lD the left inguinal
regIOn. Since the pain was increasing in severity, he visited this department in July
1985. A large tumor extending from the left ischium to the acetabulum was found.
After open biopsy, the tumor was resected in September 1985. The lateral part of
the acetabulum was left in place, but the femoral head was unstable and remained
dislocated on the posterior side of the iliac wing. At 2 years and 7 months after
operation, a radiograph revealed that the head of the femur was facing the iliac
wing in the posterior region of the acetabulum (Fig. 2 a, b, c). Leg-discrepancy is 4
em, and 3cm of heel lift is used. The patient feels no pain even on playing a round
C2-a)
C2-b)
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of golf.
MASATSUGU TAKAMI, et al.
C2-c)
Figure 2a: Giant cell tumor of left ischium and acetabulum
2b: Radiograph after excision of tumor
2c: Computed tomography scan demonstrating the head of femur placed
behind the iliac wing
Case 5: 20-year-old man
In August 1993, the patient fell while driving a motorcycle, and pain subsequently
developed in the left inguinal region. Since the pain continued, he was examined in
this department. After open biopsy, preoperative radiotherapy (61 Gy) and
chemotherapy were performed. In February 1994, the tumor was resected. At 1
C3-a)
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Eunctional Evaluation of Flail Hip Joint
C3-b)
C3-c)
Figure 3a: Ewing's sarcoma of left pubis and acetabulum
3b: Radiograph after excision of tumor
3c: Computed tomography scan demonstrating the head of femur placed
in front of the sciatic notch
year and 6 months after operation, the head of the femur was placed in front of the
sciatic notch, and weight-bearing appeared to be between the upper side of the neck
of the femur and the iliac wing. Although he has 2 cm heel lift, he can walk for
300 m without the use of a cane (Fig. 3 a, b, c).
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MASATSUGU TAKAMI, et al.
Discussion
When we treat patients with tumors that require sacrificing the pelvis involving
acetabular region, we have been performing a flail hip joint procedure rather than
reconstructive surgery. When the ilium, and particularly the thick portion of the
supraacetabular pelvic neck, is left in place, the weight load was delivered and the
operated legs functioned well regardless of whether the head of the femur was placed
anterior (Case 5) or posterior (Case 2) to the iliac wing. However, when only a
thin portion of the upper iliac wing remained in place, the load was not delivered
well and the function of the operated leg was not good (Case 3). Following total
resection of the ilium including the acetabular region (Case 4) or hemiresection of
the pelvis (Case 1), the weight load was delivered primarily via the soft tissue, and
the function of the operated leg was poor. However, little pain was felt even in
these cases. Although cane or crutches were required by these two patients, walking
ability was retained, and thus much better function seems to be retained than after
hindquarter amputation.
The disadvantage of the flail hip method is that a larger leg-length discrepancy
results than with other methods. However, when the femoral head rises upward,
the dead space decreases in size and the operative wound will heal more easily. In
a study by O'Conner and Sim [9J, for 60 patients with pelvic tumor, debridement­
requiring infection occurred in 14 legs (23%). In the present study, infection was
observed in 1 of 5 cases, but the patient who developed had undergone preoperative
radiotherapy. In the other 4 cases, the operative wound healed without problem.
When the flail hip joint is used, no internal fixation devices or spica cast is required,
unlike arthrodesis or pseudarthrosis. According to Enneking et al. [2J, the function
of the operated leg is decreased in order of arthrodesis, pseudarthrosis and flail hip.
However, if one places clinical priority on hip joint motion, one or the other of the
last two methods should be chosen. Postoperative pain in patients with pseudar­
throsis is said to be unpredictable [7J. Therefore, the flail hip joint is the simplest
method and should be considered treating in women or sedentary patients.
References
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oncology, Enneking, W.F., Churchill Livingstone, New York 117-135 (1987)
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Eunctional Evaluation of Flail Hip Joint
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Received May 26, 1997
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