Johns Hopkins Orthopaedic Surgery
May 18, 2015

The removal of metastatic disease around the acetabulum presents not only surgical challenges but logistical challenges as well.

“The point where patients are in the process of their cancer treatment will determine the best time for surgery,” says Adam Levin, an orthopaedic oncologist who specializes in complex reconstructive options for metastatic disease that has spread to the pelvis.

Reconstructing approximately 12 cases of metastatic disease in the acetabulum annually — twice the national average for specialists in the field — Levin knows that achieving the best surgical outcomes requires close coordination among medical oncologists, pathologists, orthopaedic surgeons, radiologists and rehabilitation specialists.

“If we’re not all on the same page,” he says, “I can disrupt a patient’s systemic treatment.”

For example, prior to surgery, Levin needs to know exactly when chemotherapy or radiation was administered because it could affect healing due to effects on the immune system or blood flow.

He and the team also confer to plan any postsurgical chemotherapy and radiation. In some cases, surgery could delay the start or continuation of other treatments. In other cases, medical oncologists may recommend surgery to get patients walking again so they can tolerate chemotherapy.

“If one of us wasn’t cognizant of the process, it could impair the patient’s ability to heal and go on to chemo, and then the patient gets worse,” he says.

For complex surgeries, Levin often works with orthopaedic oncologist Carol Morris to decrease the time the surgery takes, which can be as much as a full day.

More typically, the procedure involves scooping out the bone in the pelvis where the cancer has spread and then killing any remaining tumor cells with a local adjuvant, or by freezing or burning the area. After that, the reconstruction begins.

“There isn’t always much good bone left to be able to attach an implant to,” says Levin, “so we use modified hip replacement implants, bone cement and long screws to re-create the pelvis, particularly the hip socket. It results in a stable replacement that will last the patient’s lifetime.”

Sometimes both acetabula are broken, and Levin uses large screws that enter other areas of the pelvis, almost like rebar. “Then,” he says, “even after months of not walking, patients are able to walk out of the hospital.”