Reducing complications after resection of pelvic bone sarcomas : an aggregation of marginal gains

Primary pelvic bone sarcomas are rare and their treatment remains complex, with reconstruction after resection remaining controversial due to high complication and revision rates. Both prosthetic and non-prosthetic reconstructions carry risks including infection, implant failure, wound problems, and reoperation. The aim of this study was to review the changes in the management of these patients over the 20-year period between 2003 and 2023.

This was a retrospective cohort study including 479 patients who underwent surgery for a primary pelvic sarcoma during this time, divided into a historical (2003 to 2012) and a modern (2013 to 2023) group. Postoperative complications and the rates of return to theatre (RTT) were compared, and factors associated with improved outcomes were analyzed.

Early RTT within six weeks decreased significantly from 22% in the historical cohort (n = 38) to 14% in the modern cohort (n = 42; p = 0.021). Historically, the ilioinguinal incision was associated with a 44% early rate of RTT (n = 8), compared with 10% when using the question mark incision in the modern cohort (n = 10). In the modern cohort, the rate of early RTT was similar between those with prosthetic (17%; n = 13) and non-prosthetic reconstructions (13%; n = 29) (p = 0.344), although the long-term rate of RTT remained significantly higher in the prosthetic group (p = 0.007).

These findings show a clear reduction in complications and rates of RTT following pelvic resection and reconstruction for patients with a primary pelvic bone sarcoma. Although no single factor can fully account for this improvement, it probably reflects a progressive refinement of surgical strategy combined with both technical and organizational advances. These were due to changes in surgical approach and an increased use of navigation and patient-specific implants, improved preoperative imaging and planning, and a more precise understanding of oncological margins and pelvic biomechanics. The centralization of care has also not only concentrated cases into high-volume centres but has encouraged further sub-specialization within these centres, allowing cumulative expertise to develop among a limited number of highly experienced surgeons. Ongoing refinement of surgical technique leading to fewer revisions due to reduced early complications and dislocations, supported by multidisciplinary decision-making, will remain key to achieving further progress.