Leadership and innovation in oncological reconstructions

Restoring pain-free mobility that improves a patient's quality of life is chief among the satisfactions of orthopedic surgery. For Matthew P. Abdel, M.D., an orthopedic surgeon at Mayo Clinic in Rochester, Minnesota, this is especially true for reconstruction surgery after oncologic tumor resections.

The most grateful patients

"Cancer is a difficult experience for many patients," Dr. Abdel says. "The fact that we can most often make improvements they never expected is such a motivating and rewarding experience. These are the most grateful patients in the world because they go from being bedridden, fighting an often end-stage, debilitating disease to bearing weight on their legs the day after surgery, allowing for more quality time to spend with family."

Innovation and expertise

The team's special emphasis is on periacetabular tumors. Often these require radical reconstructions that lack natural anatomy to build upon.

Mayo's successful innovation in the field is based on the leadership of the orthopedic surgery team of Franklin H. Sim, M.D., and David G. Lewallen, M.D., at Mayo Clinic's campus in Minnesota. Their pioneering expertise and refined techniques helped develop team-based protocols and designed structural elements that include highly porous metal components such as cups and augments reinforced with cages.

"A key reason we maintain a high-level oncology and reconstructive practice is our ability to work as a team to develop surgical techniques and implants to improve patient care and outcomes. Our group continues to care for patients from around the U.S. and around the world with challenging pelvic cancers," explains Peter S. Rose, M.D., an orthopedic surgeon at Mayo Clinic's campus in Minnesota, and Dr. Abdel's teammate who performs the tumor resections.

Reconstruction as jazz

To Dr. Abdel, orthopedic surgery procedures such as primary total hip or knee arthroplasties are akin to symphonic performances of Beethoven. "In a primary total hip or knee, you execute 100 steps in the exact manner, and you do it the exact same way every time — the same way professional musicians perform Beethoven in the same way every time. No variation," he says. "That's how you get the best patient outcomes in those situations."

Oncological reconstructions are different; they are improv. In that way, they are more like playing jazz. The reconstruction surgeon responds creatively and originally to cues — in this case, anatomic circumstances and biomechanical constraints as they are revealed in real time — in an individual effort to support an ensemble outcome. "Until the resection is over, the tumor is removed, and the margins are established, you just don't know what you have to work with," Dr. Abdel explains.

"Every case is highly individualized. You have to react in real time with creative resourcefulness to what you have before you — and what you can contribute to it. It's the need to be creative on the spot, adjusting for each patient's individual anatomy and circumstances that I find so compelling about reconstructive surgeries. Every patient's reconstruction is strikingly different."

The narrow window

Patients who need oncological reconstruction have an extremely narrow window of opportunity during which they can safely undergo the surgery. They must stop chemotherapy treatment of their cancer, and stay off it for a short period of time after surgery to avoid jeopardizing the success of the reconstruction with side effects of the powerful drugs.

Mayo care teams balance each patient's constitutional readiness to benefit maximally from the procedure with the possibly life-endangering effects of delaying chemotherapy. When they determine that balance, the window for reconstruction opens. "I just get a call and it's time — I never really know precisely in advance when the surgery will happen," Dr. Abdel says.

Goals of reconstruction

While scheduling the reconstruction may be highly variable, the surgical goals are clear and well-established:

  • To secure rigid fixation on compromised — or nonexistent — bone
  • To achieve biologic fixation on some distant host bone that supports ingrowth of bone into metallic reconstruction components

Failure to achieve these two goals puts the patient at risk of developing major complications from the reconstruction surgery.

Explains Dr. Abdel: "The fixation to host bone has to be rock solid. We often use multiple fanning screws and a reinforcement cage to make it rigid, grabbing onto host bone that is often far away from the 'traditional' hip joint."

Elements of success

Success in this kind of complex orthopedic surgery is based in Mayo Clinic's hallmark interdisciplinary teams. The collaboration of experts in separate, highly technical yet complementary fields — oncology, orthopedic surgery, pathology, physical medicine and rehabilitation — all align in a single shared goal: patient well-being.

Other elements include a high-volume practice that supports mastery, advanced research laboratories that continually improve and evaluate outcomes, and a department commitment to ongoing professional education, skill refinement and creative growth.

Says Dr. Abdel: "For me, being part of the Mayo Clinic team doing these complex reconstructions is the most invigorating part of my practice. It's why I went into medicine: to do the right thing for the patient, always."