Surgical inaccuracy of tumor resection and reconstruction within the pelvis: An experimental study

Abstract

Background and purpose Osseous pelvic tumors can be resected and reconstructed using massive bone allografts. Geometric accuracy of the conventional surgical procedure has not yet been documented. The aim of this experimental study was mainly to assess accuracy of tumoral resection with a 10-mm surgical margin, and also to evaluate the geometry of the host-graft reconstruction.Methods An experimental model on plastic pelvises was designed to simulate tumor resection and reconstruction. 4 experienced surgeons were asked to resect 3 different tumors and to reconstruct pelvises. 24 resections and host-graft junctions were available for evaluation. Resection margins were measured. Several methods were created to evaluate geometric properties of the host-graft junction.Results The probability of a surgeon obtaining a 10-mm surgical margin with a 5-mm tolerance above or below, was 52% (95% CI: 37-67). Maximal gap, gap volume, and mean gap between host and graft was 3.3 (SD 1.9) mm, 2.7 (SD 2.1) cm 3 and 3.2 (SD 2.1) mm, respectively. Correlation between these 3 reconstruction measures and the degree of contact at the host-graft junction was poor.Interpretation 4 experienced surgeons did not manage to consistently respect a fixed surgical margin under ideal working conditions. The complex 3-dimensional architecture of the pelvis would mainly explain this inaccuracy. Solutions to this might be to increase the

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“…Additionally, the angles of inclination between the target plane and best-fit planes were calculated. Similar to previous reports [6,7] and to ISO parameters [12], the angles of inclination were measured by projecting the target and resection planes in a plane parallel to the approximate anatomic AP axis of the femur (the front angle) and in a plane approximately parallel to the anatomic sagittal axis of the femur (the depth angle) (Fig. 10).…”

“…In reality, however, the standard tools and techniques used by orthopaedic surgeons can substantially limit the ability to reliably and consistently reproduce the ideal preoperative plan at the time of resection [6] with potentially serious consequences. For instance, the surgeon may inadvertently cut into the tumor during surgery.…”

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“…Intraoperatively, image guidance with the help of fusion images provided precise visual orientation. Cartiaux et al [7] investigated the surgical accuracy of an experienced surgeon in performing a pelvic tumor resection with a 1-cm surgical margin. They reported that the surgeon could achieve a 1-cm surgical margin (± 5 mm) with a probability of only 52%.…”

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“…Cartiaux et al demonstrated that even in an ideal surgical situation, with four experienced surgeons operating on plastic pelvic models with complete visualization and accessibility to bone surfaces, the probability of achieving a good surgical margin was only 52% (95% CI: 37-67%). In addition, reconstruction correlations between host-graft junction parameters were found to be poor [4]. A subsequent geometrical model study by Cartiaux et al demonstrated that improvements in cutting accuracy could be achieved when CAOS was integrated into a freehand bone-cutting process [5].…”