Reconstruction after total En Bloc sacrectomy for osteosarcoma using a custom-made prosthesis

Study Design: A report of an innovative technique to restore the lumbosacral junction after resection of primary highly malignant osteosarcoma of the sacrum involving the whole sacrum, soft tissues, and adjacent posterior parts of both lilac wings. Objectives: To describe the planning and design of a custom-made sacral prosthesis, the surgical technique, and clinical and functional outcome of the patient. Summary of Background Data: Although there have been case reports about reconstruction methods after total sacrectomy, to date, there has not been a reported clinical case of successful reconstruction using an individual designed prosthesis based on a three-dimensional real-sized model. Methods: A 42-year-old woman was referred with progressive neurologic impairment due to primary osteosarcoma of the sacrum invading surrounding structures. Based on a three-dimensional real-sized model, a detailed surgical plan was developed to assure safe, wide surgical margins. In addition, the model enabled design and testing of a custom-made sacral prosthesis, to provide stable lumbosacral reconstruction. Results: After induction chemotherapy, a staged anteroposterior resection-reconstruction was successfully performed. After surgery, a superficial wound dehiscence was promptly treated. Within 3 weeks after surgery, mobilization began, and the adjuvant chemotherapy was continued. At the 36-month follow-up, the patient was disease free, had a stable, painless spinopelvic junction, and could walk short distances using ankle orthoses and crutches. Radiographs show complete incorporation of the pelvic grafts and unchanged position of the implant. Conclusions: In planning and performing a total sacrectomy, including substantial parts of iliac wings, a three-dimensional real-sized model offers surgeons distinct advantages. Wide bony resection margins can be drawn on the model, and an individual custom-made prosthesis to re-establish spinopelvic continuity can be designed and tested before the intervention.