NF, was an eighteen-year-old lady when she first presented to us about 3years ago. Diagnosed with Chrondromyxoid Fibroma of the left pelvis, it had been more than a year since she walked independently without support. Patient and her parents after consulting tens of surgeons and visiting 3 different countries landed at our doorstep. To have a normal gait and lead a pain free life was the primary goal for the patient and seeing their daughter happy, able to stand on her own legs, to be able to start her own family… was her parents dream.
Though handling such complicated cases constituted the main chunk of our operative work load, this case in particular was a challenging task for us; considering the age of the patient, site and extent of the lesion and the targets to be achieved. The lesion was extensive, involving whole of the left pelvis with extension into the pelvic cavity and hip joint. After thorough radiological and clinical evaluation, discussion at the multidisciplinary tumour board meetings and counselling sessions with the parents and attenders; patient was planned for a staged approach.
The first step involved debulking of the lesion in the pelvis by a minimally invasive approach and innovative techniques (ultrasonic probe) to obtain a well-defined cavity to address. The in the second step, thorough curettage was performed along with girdle stone arthroplasty, to make sure no residual tumour tissue is left behind. The patient withstood both the procedures well and was started on physiotherapy to maintain the limb function and denosumab therapy for a healthy and strong bone bed to be formed, which would later help us as a robust foundation for reconstructing the hip joint. The patient was closely followed up for the next two years. She showed no signs of local recurrence or distal metastasis and was prepared for the next testing task.
The native remaining pelvis for the patient was distorted due to the tumour and prior surgery. Computed tomography (CT) and magnetic resonance imaging (MRI) scans of the patient were performed, uploaded, superimposed and reconstructed to obtain a life like digital model of the pelvis to be operated upon; in order to design patient specific 3D printed models and implants. After multiple analyses, brainstorming sessions and close alliance with the engineers, a biocompatible titanium implant which could substitute the left pelvis was designed and imported from Germany, after its printing. The surgical procedure was also demanding as the implant had to be placed at specific location and angles to acquire the best fit. The screws meticulously designed to anchor the prosthesis at the right place, had to be fit at the predetermined locations. The 3D printed plastic guidance jigs designed for this error-free purpose helped us get a consummate reconstruction. The postoperative wound care and physiotherapy was as important as the surgery and the patient was mobilized early, under extreme care and assistance. Patient recovered without any untoward events and was up and about sooner than expected, on her own legs after many months.
Complex pelvis resections and reconstruction are never an easy task and this kind of custom made 3D printed implant reconstruction of the pelvis is one of the first to the performed in the country. In this era of evolving relationship between technology and medicine, revolutionizing health care; our prior experience with 3D printed models and its application for surgical practice helped us to move a step ahead in utilizing this technology. Understanding the biomechanics of load transmission across the pelvis to the lower limb, keeping in mind the anatomical restraints of the patient, engineering an implant with a sublime fit which could make the patient walk comfortably, was a daunting task.
Collaboration of medicine and technology is becoming the antidote for issues that formerly caused despair, for both the patient and the surgeon. We feel the need for a generation of physicians and surgeons, who are technologically skilled and adapted toward innovation. As Noor and her family fly back home content, the smile on their face makes us push harder to break new boundaries, for the betterment of cancer care and a happy, healthy society.