Pelvic Resections

■ Feature Article

Pelvic Resections

ANDREAS F. MAVROGENIS, MD; KONSTANTINOS SOULTANIS, MD; PAVLOS PATAPIS, MD; GIOVANNI GUERRA, MD; NICOLA FABBRI, MD; PIETRO RUGGIERI, MD, PHD; PANAYIOTIS J. PAPAGELOPOULOS, MD, DSC

abstract Full article available online at ORTHOSuperSite.com. Search: 20120123-40

The complexity of pelvic anatomy and the extent of tumor growth makes treatment of patients with primary bone sarcomas in the pelvis diffi cult in terms of local con- trol. Before the 1970s, most tumors in the bony pelvis were surgically treated with hindquarter amputation. Currently, improved techniques for clinical staging, adjuvant treatments, evolutions in metallurgy, and development of new surgical techniques make limb-salvage surgery and reconstruction possible alternatives to hemipelvec- tomy and resection–arthrodesis. The advantages of amputation over resections at the pelvis are a lower incidence of complications, a limited area at risk for recurrence, and a faster recovery time compared with all but the most limited pelvic resections. The disadvantages, especially after periacetabular resections, are leg-length discrepancy and impaired hip and gait function. The indication for limb salvage is the ability to obtain wide margins without compromising survival and function. Although having to resect the sciatic nerve to obtain adequate margins does not always mean that an amputation should be performed, the combination of a major pelvic resection and the functional consequences of sciatic nerve resection results in an extremity usually not worth saving; loss of femoral nerve function does not result in a signifi cant gait Figure: Types of pelvic and proximal femoral re- sections. disturbance, especially if the hemipelvis is stable. Reconstruction options after major pelvic resections have also evolved, but they remain diffi cult, especially when the acetabulum is involved.

Drs Mavrogenis, Soultanis, and Papagelopoulos are from the First Department of Orthopaedics, and Dr Patapis is from the Department of Surgery, ATTIKON University Hospital, Athens University Medi- cal School, Athens, Greece; and Drs Guerra, Fabbri, and Ruggieri are from the Fourth Department of Orthopaedics, Istituto Ortopedico Rizzoli, Bologna, Italy. Drs Mavrogenis, Soultanis, Patapis, Guerra, Fabbri, Ruggieri, and Papagelopoulos have no relevant fi nancial information to disclose. Correspondence should be addressed to: Panayiotis J. Papagelopoulos, MD, DSc, First Department of Orthopaedics, ATTIKON University Hospital, Athens University Medical School, 1 Rimini, Chaidari, Athens, Greece ([email protected]). doi: 10.3928/01477447-20120123-40

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rimary bone sarcomas of the pel- compromising function.20,23,24,27 Con- be positioned in line with the eventual re- vis account for 5% to 10% of all traindications for limb salvage, which section incision. Most pelvic sarcomas are Pmalignant bone tumors, the most means indications for a hindquarter am- resected through an incision over the iliac common of which are chondrosarcomas, putation, include: (1) patients who had crest; therefore, the safest biopsy incision Ewing’s sarcomas, and osteosarcomas.1-4 a resection in the past but now have lo- is directly over the iliac crest.24 If needle The prognosis and survival of patients cal recurrence, unless the recurrence biopsy is not diagnostic, open incisional with bone sarcomas in this location are can defi nitely be widely resected or the biopsy is recommended. Every attempt much less favorable than for patients with amputation offers no oncological benefi t; should be made to not contaminate the tumors of the extremities.5-8 The treatment (2) a tumor that has extended across the retroperitoneum. Transrectal, ultrasound- in this location is also diffi cult in terms of sacroiliac joint to the sacral nerve root guided needle biopsy should be avoided local control because of the complexity of foramen; and (3) patients with lesions for anterior sacrum tumors due to the risk pelvic anatomy, which increases the dif- extending into the sciatic notch who of contamination.23 fi culty of resection and reconstruction.8-19 have symptoms of sciatic nerve involve- Restaging should be performed after Before the 1970s, most tumors in the ment.1,20,21,23-27,31 preoperative chemotherapy and radiation bony pelvis were surgically treated with Although having to resect the sciatic therapy to predict the adequacy of the hindquarter amputation. Over the next nerve to obtain adequate margins does not planned tumor resection and assess the decades, planning tools and imaging tech- always mean that an amputation should surgical margins in 3 dimensions (sagittal, niques greatly improved and made it pos- be performed, the combination of a ma- coronal, and frontal) and 6 planes (proxi- sible to defi ne the exact extent of a tumor jor pelvic resection with the functional mal, distal, anterior, posterior, lateral, and and its relation to functionally important consequences of sciatic nerve resection medial).20,23-25,27,31 Current technology structures, such as the nerves, blood ves- results in an extremity usually not worth based on CT data from the bony pelvis sels, and intestinal organs.1,20-28 Currently, saving. The femoral vessels can be by- may produce an individual 3-dimensional improved techniques for clinical stag- passed (although it is more diffi cult to pelvic model for preoperative planning of ing, adjuvant treatments, evolutions in bypass the femoral vein), and the loss of the line of resection and an accurate re- metallurgy, and development of new femoral nerve function does not result in construction for a good fi t to the remain- techniques in oncologic reconstruction a signifi cant gait disturbance, especially if ing part of the pelvic bone.33 make limb-salvage surgery and recon- the hemipelvis is stable.20,23,24,27 The resection is usually planned for struction at the pelvis possible as alterna- 2 to 5 weeks after the last chemotherapy tives to hemipelvectomy and resection- STAGING AND SURGICAL PLANNING session and 4 to 5 weeks after radiation arthrodesis.9,12,14,17,23,27 Imaging studies, including plain ra- therapy.24 An absolute neutrophil count Currently, so much experience has diographs, computed tomography (CT) of 500 to 1000 cells per µL and a plate- been gained from primary tumor surgery scans, and magnetic resonance imaging of let count of at least 50,000 cells per µL is that limb-salvage surgery is also per- the pelvis and radiographs or CT scans of required. Intraoperative radiation therapy formed for pelvic metastases in patients the chest, should be carefully examined. may be arranged after reviewing preoper- with favorable cancer types, solitary Conventional or magnetic resonance angi- ative imaging of an area in which micro- metastases, and long expected survival ography of the pelvic vessels is important scopic contamination may occur.31,34 rates.29,30 The advantages of amputation to evaluate tumor involvement and possi- A multidisciplinary approach includ- over resections at the pelvis are a lower bly to plan for wound closure with a fl ap. ing colleagues from urology, vascular incidence of complications, a limited area A venogram may also be useful if evi- surgery, general surgery, colon and rectal at risk for recurrence, and a faster recov- dence exists of tumor thromboembolism surgery, orthopedic oncology, neurosur- ery time compared with all but the most in the iliac veins.32 gery, plastic surgery, and spine surgery limited pelvic resections. The disadvan- Biopsy is the last step of staging. It is may be necessary. Prior to the procedure, tages, especially after periacetabular re- usually performed using CT guidance and the patient is evaluated by an urologist sections, are the inevitable discrepancy in a 3- to 6-mm gauge needle. The treatment for bladder and ureter involvement of the leg length and impaired hip and gait func- success relies on an appropriate and accu- tumor. Pancystoscopy and pyelouretero- tion.1,23-27 rate biopsy placed in the appropriate loca- gram can be performed to evaluate tumor tion; this is especially true for tumors such involvement; placement of ureteral stents INDICATIONS AND CONTRAINDICATIONS as chondrosarcomas, whose treatment and or a pigtail catheter may be considered if The indication for limb salvage is the outcome depend mostly on an adequate one ureter appears to be involved by a tu- ability to obtain wide margins without initial surgery.20 The biopsy track should mor.1,20,23,24,27,31

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The pubic symphysis is exposed by de- taching the anterior rectus adbominis and pyramidalis muscles from their insertion onto the ipsilateral pubic crest. Posterior to the symphysis is the retropubic, retro- peritoneal space of Retzius. The bladder is separated from the anterior pubic bones by thick, fi brous tissue and retropubic fat. The urethra is just inferior to the pubic symphysis and is separated from it by the arcuate ligament.20,23,24,27,31 Division of the symphysis is performed with an osteo- 1A 1B 1C tome or the Gigli saw from superior to in- Figure 1: Diagrams of the extended ilioinguinal approach.20 Anterior resections may require extension to ferior, with care to not damage the urethra. the contralateral pubic ramus and a vertical incision for exposure of the femoral vessels (A). Periacetabular Once the anterior cut has been completed, resections require lateral extension of the incision to the thigh (B). Posterior resections may require exten- the pelvis will open, but the sacrospinal sion to the midline of the spine (C). and sacropubic ligaments must be cut be- fore the pelvis becomes loose.20,23,24,27,31 EXPOSURE bic tubercle and continues laterally to the In the posterior pelvis, the common The standard exposure for pelvic bone anterior iliac crest. The medial two-thirds iliac vessels should be traced deep into resections involves the utilitarian pelvic of the inguinal canal represent a refl ec- the pelvis; the inferior vena cava should incision,20 which is the extended ilioingui- tion and coalescence of the internal and be protected when performing surgery on nal approach that extends from the pubic external oblique abdominal muscles and the patient’s right side. The psoas may be tubercle along the inguinal ligament to the transversalis fascia. The abdominal mus- separated from the iliacus muscle to en- anterior superior iliac spine and along the culature should be carefully dissected off hance the exposure of the sciatic notch. iliac crest to the posterior superior iliac of the iliac crest. The inguinal ligament The ureter is located because it crosses spine (Figure 1A). Periacetabular resec- should be detached at its lateral attach- the common iliac artery just distal to the tions require lateral extension of the in- ment to the anterior iliac crest and dis- pelvic brim into its junction with the blad- cision to the thigh (Figure 1B). Posterior sected off the deeper iliac fascia laterally der and is retracted medially. The sciatic resections may require extension of the and refl ected proximally. Once the ingui- nerve comes closest to the pelvis at the posterior incision to the midline of the nal ligament is released, the iliopsoas, the greater sciatic notch. Usually, the nerve spine with or without a perpendicular mid- femoral nerve and sheath, and the pelvic is not infi ltrated and comes away from line extension (Figure 1C). Anterior pelvic retroperitoneal space are exposed. the tumor’s pseudocapsule without diffi - resections, such as ischiopubic resections, The femoral bundle should be identi- culty.20,23,24,31 Next, the obturator vessels may require extension of the ilioinguinal fi ed midway between the pubic tubercle and nerve are identifi ed because they run incision to the contralateral pubic ramus and iliac crest, just anterior to the su- along the inferior lateral pelvic brim, just and an additional perpendicular T-incision perior pubic ramus. The femoral sheath anterior to the sciatic notch and gluteal for femoral vessels exposure.20,23,24,27,31 should be fully dissected, and ligation of vessels, and continue along the inferior Different parts of the extended ilioingui- the inferior epigastric vessels should be surface of the superior ramus into the ad- nal approach may be used depending on performed for all periacetabular and is- ductor compartment. the location and extent of the tumor.24 An- chiopubic resections. The femoral nerve After the vascular structures have been terior incisions to the area of the femoral lies deep into the iliopsoas muscle and visualized, the posterior sacroiliac joint vessels that extend distally and laterally, tendon, lateral to the femoral sheath, should be identifi ed. The L5 nerve root developing a lateral fl ap based on the glu- and should be identifi ed and protected. courses just below the transverse process teal arteries, are relatively risky because In men, the spermatic cord and its con- of the L5 vertebra, where the iliolumbar part of their blood supply comes from lat- tents (ductus deferens, testicular artery, ligament attaches to the posterior ilium. eral branches of the femoral artery, which and genitofemoral nerve) should be dis- The L5 joins the L4 and sacral roots are interrupted anteriorly.31 sected medially to laterally and retracted. to form the sciatic nerve at the sciatic In the anterior pelvis, the incision for In women, the round ligament may be notch.20,23,24,31 The posterior fl ap should the ilioinguinal approach begins at the pu- sacrifi ced.20,23,24,31 be as thick as possible.

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If the muscle can be saved, a myocuta- hemipelvectomy. In addition, although the neous fl ap including the gluteus maximus surgical margins may be the same, a lim- is recommended for safe wound coverage. ited area is at risk for recurrence after an If only skin and subcutaneous tissue can amputation compared with a limb-salvage be saved, an anterior thigh fl ap or alter- procedure.2,5,19,37 External hemipelvec- native fl aps should be considered, which tomy is recommended in recurrent sarco- requires salvage of the common iliac ves- mas after previous resection when there is sels.35,36 sacral involvement and extension of the tumor across the sacroiliac joint and into MAJOR PELVIC RESECTIONS the sciatic notch.5,12,31 Major pelvic resections have been When the tumor involves the poste- classifi ed by the Musculoskeletal Tumor rior pelvis and sacrum and extends to the Society into 3 resection types: type I lower lumbar spine, resection should in- (iliac), type II (periacetabular), and type clude the ilium, the entire or part of the III (obturator).20 Resections involving the sacrum, and part of the lower spine to sacrum are type IV resections. Resections obtain wide or safe surgical margins; this that involve combinations of these areas procedure is defi ned as extended hemi- are named by combining the respective pelvectomy (Figure 4). Extended hemi- numbers; for example, a resection of the pelvectomy results in a large defect with 2 entire hemipelvis would be designated subsequent destabilization of the spino- Figure 2: Types of pelvic and proximal femoral re- type I,II,III (hemipelvectomy).37-39 pelvic segment; therefore, reconstruc- sections. Pelvic resections that include the fem- tion is necessary for spinopelvic stabil- oral head have been designated as type H ity and function.9,12 It is suggested that Type I Resections and are classifi ed into 3 types: type H1 extended hemipelvectomy may be best Type I resections can be achieved (femoral head), type H2 (pertrochanteric reserved for patients with localized dis- through the posterior aspect of the stan- area), and type H3 (subtrochanteric area) ease. Considering the high failure rates dard ilioinguinal approach. The anterior (Figure 2).20,31 Major spinopelvic resec- and the increased morbidity, this type of iliac osteotomy is made through the sci- tions have been classifi ed into 4 types: surgery is not indicated for patients with atic notch or just superior to the acetabu- type 1 (total sacrectomy), type 2 (hemi- metastatic disease at onset or with other lum. The posterior osteotomy is usually sacrectomy), and type 3 and 4 (partial severely compromising medical factors made through or adjacent to the sacroiliac and total sacretomies in conjunction with at presentation. joint. The iliolumbar ligament is encoun- external hemipelvectomy).39 The specifi c In addition, performing an extended tered at the most superomedial aspect type of pelvic resection to be performed hemipelvectomy for a patient who had of the posterior iliac crest and should be depends on the area involved and the ex- prior surgeries at the same site may result released to enhance exposure. This liga- tent of the tumor.20,23,24,27,31,37-39 in an increased risk for complications ment also serves as a good landmark for and local recurrence.12,31 When compar- the L5 nerve root that should be identi- Hemipelvectomies ing the oncologic outcomes of patients fi ed just inferior and medial to the liga- Hemipelvectomies include resection who had either an internal or an exter- ment.20,23,24,27,31 of the hemipelvis with or without ampu- nal extended hemipelvectomy, no major tation of the limb (external and internal differences were detected except for the Type II Resections hemipelvectomy, respectively).5,12,31 In longer follow-up of the patients who had Type II (periacetabular) resections are deciding whether to proceed to an internal an internal procedure.12 In general, when indicated for tumors involving the acetab- rather than an external hemipelvectomy, patients require major spinopelvic resec- ulum and tumors of the hip joint or the the internal hemipelvectomy should at tion, which disrupts spinopelvic conti- proximal femur invading the acetabulum; least lead to the same tumor-free mar- nuity and either resects the lumbosacral in cases in which it appears possible to gins and provide a superior functional plexus or both the lumbosacral plexus achieve surgical margins similar to those outcome with acceptable morbidity (Fig- and hip joint, the ultimate function of obtainable with hemipelvectomy; when ure 3).2,5,7,19,37 However, the incidence of the limb is so poor that amputation of the resection can preserve a reasonably complications is lower and the patient the limb (external extended hemipelvec- functional limb (sparing at least in part the recovers more quickly after an external tomy) is often indicated.38,39 major nerves and permitting some recon-

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iliac joint involvement are treated by sag- ittal sacrectomy and limited posterior iliac resection (type I,IV resection). Above or below the S2 midline, tumors without sacroiliac joint involvement are treated by transverse sacrectomy.9,41,43 Total sacrectomy is indicated when 3A 3B a malignant or aggressive benign lesion Figure: Diagram of the pelvis shows internal involves the proximal sacrum with ante- hemipelvectomy for chondrosarcoma of the right rior extension.13,44,45 A radical surgical hemipelvis (A). Anteroposterior radiograph of the 4A 4B approach with sacral roots sacrifi ce is pelvis shows the reconstruction with ischiofemoral Figure 4: Diagram of the pelvis shows extended pseudarthrosis with cables. (B) external hemipelvectomy for chondrosarcoma of often warranted to achieve total resection the right hemipelvis extending to the sacrum and with clear margins.46 However, a total sa- lower lumbar spine (A). Anteroposterior radio- crectomy can enhance local tumor con- struction of the joint); and when the gen- graph shows spinopelvic stabilization with a rod trol and overall patient survival despite and pedicle screws construct (B). The patient is eral physical status and life expectancy of alive and disease free at 2-year follow-up. potential complications and neurologic the patient justify the procedure.22,31 dysfunction.8,42 Techniques for total sa- Periacetabular resections require 3 os- crectomy were pioneered in the 1960s and teotomies. The superior osteotomy should herniation into the inguinal defect, using 1970s.47,48 Combined dorsal and ventral always be superior to the posterior iliac a synthetic mesh, polytetrafl uoroethylene exposures have been described, and the spine (through the greater sciatic notch). (Gore-Tex; W. L. Gore & Associates, Inc, use of the transpelvic vertical rectus ab- The anterior osteotomy is usually made Newark, Delaware), or fascial allograft. dominis myocutaneous fl ap for the recon- through the anterior column of the ac- The inguinal fl oor should be appropriately struction of large sacral defects has sig- etabulum at the base of the superior pubic reconstructed from the pubic tubercle to nifi cantly reduced problems with wound ramus. The posterior osteotomy may be the lateral ilium to prevent peritoneal her- healing.18,47-52 located in the posterior acetabular column nias.40 In addition, care should be taken The general approaches to sacral tu- or the ischium. If the tumor is in the poste- for repositioning the femoral vessels (and mors include anterior, posterior, and com- rior column, it is recommended to remove in men the spermatic cord and contents) bined approaches for large, aggressive en bloc the acetabulum with the ischium into the retroperitoneal space. sacral tumors extending to S1, the lumbar (type II,III resection) (Figure 5).20,23,24,31 spine, or the pelvis. Anterior approaches Type IV Resections and Sacrectomies include either transabdominal or retro- Type III Resections Various sacrectomies have been de- peritoneal exposures, whereas posterior Type III resections require 2 osteoto- scribed depending on the tumor’s location approaches involve sacral laminectomy mies. The medial osteotomy is usually and its extension. In general, sacrectomies and partial posterior sacrectomy.53 Sacral made through the pubic symphysis; occa- have been classifi ed as partial or total and laminectomy is indicated for tumors sionally, it is necessary to extend the ap- can be combined with some posterior iliac largely confi ned to the sacral canal, such proach to the opposite pubic ramus. The resections (type I,IV resection) and resec- as neurogenic tumors, because of the ease second osteotomy is made either just me- tion of part of the lower lumbar spine (ex- of exposure to the neural elements. Sacral dial to or through the acetabulum; the hip tended hemipelvectomy).31,38,39,41 laminectomy as the primary exposure is should not be dislocated.31 Limited type Partial sacrectomy is indicated for tu- not indicated for tumors originating out- III resections may be performed (Figure mors of the sacrum below the S2 segment side the sacral canal or extending signifi - 6). In most type III resections, the obtu- because it can usually be performed with cantly into the pelvis.54 Posterior sacrec- rator artery, vein, and nerve are sacrifi ced wide margins, it does not require lum- tomy is indicated for tumors of the sacrum because of proximity to the tumor. These bopelvic reconstruction, and it preserves below the level of the sacroiliac joints, tu- are located laterally along the pelvic side- bowel and bladder function.8,42 Partial sa- mors without large presacral mass, tumors wall, coursing superfi cial to the obturator crectomy may be transverse, sagittal, or a whose superior limit can be reached on internus muscle. combination. Lateral sacral tumors with- digital rectal examination, and smaller le- Following most type III resections, a out sacroiliac joint involvement are treat- sions of the middle and distal sacrum not careful soft tissue reconstruction should be ed by sagittal partial sacrectomy. Above yet requiring resection above the level of performed to prevent bladder or intestinal or below the S2, lateral lesions with sacro- the sacroiliac joint.54

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A combined anteroposterior approach is indicated for tumors with extensive vas- cularity, primary proximal sacral tumors engaging the lumbosacral junction (in particular the upper S1 endplate), and tu- mors with signifi cant presacral mass that penetrate the anterior pelvic fascia or in- volve the rectum.23,24,31,55 5A 5B 5C A synchronous abdominosacral ap- proach to expose the sacrum anteriorly Figure 5: Anteroposterior radiograph of the pelvis shows chondrosarcoma of the left periacetabular area and ischiopubic rami (A). Diagram of the pelvis shows type II,III resection (B). Anteroposterior radiograph and posteriorly simultaneously in the shows reconstruction with iliofemoral pseudarthrosis with wires (C). lateral position for resection of sacral tu- mors has also been reported.48 However, Figure 6: Anteroposterior with this approach it is more diffi cult to radiographs of the pelvis show Ewing’s sarcoma of expose both the anterior and posterior sa- the right ischiopubic rami crum, and the lateral position complicates (A) and limited type III efforts at soft tissue reconstruction or me- resection without recon- chanical stabilization, if necessary.48 struction (B).

Hemicorporectomy Hemicorporectomy or translumbar am- 6A 6B putation involves amputation of the pelvis and lower extremities by disarticulation through the lumbar spine with concomi- threatening diagnoses that resulted in of the aorta, inferior vena cava, and spinal tant transection of the aorta, inferior vena complications of massive bleeding, soft cord in an anterior-to-posterior approach.57 cava, and spinal cord and the creation of tissue necrosis, sepsis, congestive heart Disarticulation through the lumbar spine conduits for diversion of the urinary and failure, and bowel and bladder inconti- and division of the spinal cord is associated fecal streams.56-58 Originally described in nence.56,57,64 with untoward blood loss and neurogenic 1950, Ͼ50 cases of hemicorporectomy Hemicorporectomy has been per- hypotension, which likely contributes to have been reported.56-58 Indications in- formed for carcinomas of the bladder, cer- morbidity and length of hospital stay. After clude the following: vix, vagina, and prostate and bone tumors ligation of the inferior vena cava, Batson’s ● Locally advanced cancer confi ned to the of the pelvis, including giant cell tumors plexus becomes engorged, leading to a pelvis and lower body that failed to re- and chordomas of the sacrum and chon- more challenging dissection and marked spond to traditional therapies. drosarcomas.62 Patients with chordomas blood loss during division of the vertebral ● Slow-growing malignancies confi ned to whose local resection or irradiation failed structures and spinal cord.57,58 However, the lower body and certain benign condi- were excellent candidates for hemicorpo- hemicorporectomy results in such serious tions, most of which are complications of rectomy because these tumors grow slow- mutilation that it is questionable, from an paraplegia.59,60 ly and rarely spread to distant sites; most ethical standpoint, whether it should be of- ● Inoperable pelvic tumors by abdomino- of these patients eventually die from com- fered to patients.62 Use as a palliative pro- perineal resection, pelvic exenteration, or plications associated with local invasion, cedure is precluded.62 hemipelvectomy with absolute absence such as intestinal or urinary obstruction, of evidence of tumor metastasis outside bleeding, or sepsis.64 Paraplegics repre- PELVIC RECONSTRUCTIONS of the pelvis.61 sent the majority of translumbar amputa- The indications for pelvic reconstruc- ● Biologic nature of the tumor compatible tions for benign processes.57 tion include young patients, resection of with prolonged survival.61,62 Hemicorporectomy is performed in weight-bearing or moving elements (such ● Severe crushing trauma to the pelvis and 2 stages. During the fi rst stage, conduits as the hip joint), primary sarcomas or be- lower extremities.56 for diversion of both the urinary and fe- nign aggressive tumors with intention to ● Acute aortic occlusion.63 cal streams are constructed. The second cure, solitary pelvic bone metastasis in ● As a last resort in the treatment of pelvic stage includes disarticulation through the patients with “favorable” cancers such arteriovenous malformations and life- lumbar spine with concomitant transection as thyroid, renal, and breast cancer with

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7A 9A 8 Figure 8: Type I,II resection for Ewing’s sarcoma of the right ilium and periacetabular area, and fl ail hip reconstruction stabilized with 2 artifi cial ligaments.

allografts (Figure 9), iliac allograft com- posites with a hip arthroplasty, custom- made metallic pelvic prostheses, saddle 7B prostheses, or stemmed prostheses (Figure 9B 10).14,74-76,81,82 Each reconstruction option Figure 9: Anteroposterior radiographs of the pel- Figure 7: Axial computed tomography scan of the vis show chondrosarcoma of the left ischiopubic pelvis shows Ewing’s sarcoma of the left ilium (A). has its own advantages and disadvantages, rami and periacetabular area (A) and type III resec- Anteroposterior radiograph of the pelvis shows and most studies report a high failure rate; tion with allograft reconstruction of the acetabular type I resection and reconstruction with bone ce- it is generally best to do the easiest recon- fossa (B). ment, Steinman pins, and screws (B). struction possible.71-81 Flail hip does not involve a skeletal re- long life expectancies, and the availabil- constructive procedure, only a soft tissue tionplasty with calcaneosacral arthrodesis ity of materials relative to the timing of closure. Pseudarthrosis and arthrodesis in- and the hip transposition, have also been surgery.65 The following alternatives are volve establishment of a fi brous or solid reported after external hemipelvecto- available for reconstruction of the pelvis union, respectively, between the proximal mies.69,70 The tibia–hindfoot rotationplas- or reattachement of the extremity follow- femur and the remaining pelvis (iliofemo- ty with calcaneopelvic arthrodesis is ap- ing pelvic resections: fl ail hip, pseudar- ral, ischiofemoral, or sacrofemoral) using plicable in selected patients with unaffect- throsis, arthrodesis, megaprosthetic, or a plate or similar implant, cables, cerclage ed external iliac and femoral vessels and allograft reconstruction.66-81 wires, or screws.66-68 Disadvantages of involves a modifi ed anterior fl ap hemipel- arthrodesis include loss of the function- vectomy with resection of the femur and Reconstructions for Type I and III ing hip joint, which is not recommended hemipelvis but preservation of structures Resections in younger patients, shortening of the below the knee. The calf with its vascu- The bony defect in type I resections leg, lack of mobility, and long consolida- lar supply is rotated by 180º, the fore- and can be reconstructed with autograft fi bula, tion times, which means longer periods midfoot are resected, and the calcaneus cortical or pelvic allograft, or bone cement of rehabilitation and the use of gait sup- is fi xed to the osteotomy site at the sa- (Figure 7). The advantages of replacing port.20,27,83,84 Hip spica cast immobiliza- crum.68,69 The hip transposition technique the resected bone are pelvic stability and tion is required postoperatively for ap- involves refi xation of the inferior part of maintenance of limb length. The disad- proximately 3 months to obtain union of the acetabulum to the preserved bone (il- vantages are the increased risks of infec- the arthrodesis.31,65 ium or sacrum) after 90º rotation (type I) tion and failure of the reconstruction.31 No Fusion rates of femoropelvic arthrod- and wrapping the femoral head (type IIa) formal reconstruction is required for type eses are Ͻ50%. In most patients, a stable or a proximal femoral bipolar megapros- III resections. and painless pseudarthrosis develops, thesis (type IIb) into an artifi cial capsule but with a comparable functional result that is attached to the intact proximal bone Reconstructions for Type II Resections to that of the alternative reconstruction (ilium or sacrum) with bone anchors.70 Defects can be reconstructed with a options.31,65 Alternative arthrodesis tech- Arthroplasty reconstructions are rec- pseudarthrosis (Figure 8) or arthrodesis, niques, such as the tibia–hindfoot rota- ommended when adequate ilium and pu-

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bis remain for fi xation of a pelvic allograft composite with a unipolar or total hip megaprosthesis. Pelvic allografts should be carefully selected and matched. Large femoral head sizes (у32 mm) should be chosen, and the periacetabular soft tissues and gluteal fascia should be reattached to maximize postoperative hip stability.31 Custom-made metallic pelvic prostheses are expensive. The 3 linking areas for the 10A 10B pelvic prosthesis are the remaining or the 11A 11B Figure 10: Anteroposterior radiographs of the left opposite pubic rami, the joint facet of the Figure 11: Anteroposterior radiographs of the left hip show chondrosarcoma of the left periacetabu- hip show Ewing’s sarcoma of the left periacetabular sacrum or the remainder of the ilium, and lar area and ischiopubic rami (A) and type II,III area and ischiopubic rami (A) and type II,III resec- the remaining ischium.78,81 resection and reconstruction with a cemented tion and reconstruction with a saddle prosthesis (B). With the prosthesis in place, the ac- stemmed prosthesis (B). etabular prosthesis should be symmetric with the contralateral side in height, lat- fect after total sacrectomy because of the screw–rod construct. Pedicle screw instru- eral distance, and orientation.81 Saddle risk of major wound complications (espe- mentation is performed into at least the prostheses provide good cosmetic result cially deep wound infection) after recon- lowest 3 segments of the lumbar spine, and and limb-length equality (Figure 11); struction and the acceptable ambulatory screw fi xation is obtained in the bone stock however, the eccentric position of the status of the patients without reconstruc- of the remaining ilium, avoiding the hip new hip center reduces the range of mo- tion.91-93 However, most authors recom- joint. Rods are placed in the spinal pedicle tion, and loosening, lateral shift, or dislo- mend lumbopelvic stabilization after total screws and the iliac screws connecting the cation of the prosthesis is common.71 In sacrectomy, partial sacrectomy involving lumbar and pelvic segments. A part of the this regard, artifi cial ligaments have been Ͼ50% of the sacroiliac joint on each side, femur (usually the femoral condyles) of the used to secure the saddle and convention- and sagittal and high transverse partial amputated limb that is tumor free is saved al proximal femoral megaprostheses un- sacrectomy that essentially obliterates the sterile and used as strut graft to bridge the til a fi brous pseudocapsule develops.82,84 sacroiliac articulation unilaterally or bi- gap between the remaining lumbar spine laterally and destabilizes the lumbopelvic and pelvis on the retained side.38 The ped- Reconstructions for Type IV Resections segment.9,10,42,43,87-90 icle screw–rod construct for spinopelvic Sacral resections below S1 are struc- Spinopelvic stabilization after major reconstruction is easier to place safely, and turally stable and seldom require recon- spinopelvic resections has been attempted the fi xation is more rigid than that of previ- struction; stability is preserved because using various constructs with combina- ous constructs. However, long-term follow- the conventional S2-S3 partial sacrec- tions of screws, wires, bars, and plates.* up is still not available.10,12 tomy does not disrupt the sacroiliac ar- Spinal fi xation using sacral bars and ticulations and lumbopelvic structure. Harrington rod constructs (Zimmer, Inc, WOUND CLOSURE Conversely, sacral tumors at the S1 level Warsaw, Indiana) with combinations of In the past, the defects created by these alter the biomechanics at the lumbosacral hooks, wires, and pedicle screws, and the procedures were closed primarily, result- junction, and therefore may require stabi- Luque-Galveston technique (segmental ing in wounds subjected to considerable lization.13,38,39,41,85-93 spinal instrumentation through the use of tension and high rates of complications, After total sacrectomy, the lumbar sublaminal wiring and iliac fi xation to the such as wound dehiscence, hematoma spine usually migrates inferiorly and re- pelvis) have fueled the evolution of recon- formation, and infection. To overcome mains between the ilia.9,10 The muscles struction techniques in the past.12,13,42,85,94,95 these problems, pedicled or free myocu- and the scar between the pelvis and spine However, although fi xation to the pelvis taneous fl aps have been used for wound form a biological sling, eventually stabi- improved, proximal fi xation was tenuous, closure, and polytetrafl uoroethylene mesh lizing the spine. Most patients are able to and stability was diffi cult to achieve. (Gore-Tex) and acellular dermal matrices walk with a brace, with only slight back or The current instrumentation used in GraftJacket (Wright Medical Technology, leg pain.42,45,90,91 spinopelvic reconstruction is the pedicle Arlington, Tennessee) are used to repair In this setting, some surgeons do not retroperitoneal defects and prevent her- advocate reconstruction of the osseous de- *References 12,13,16,38,39,42,55,85,87,94-96. nias.35,97-99

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However, regardless of the level of li- the internal iliac artery in an end-to-end gation of the iliac vessels, the factor that fashion.23,109,111-113 Free microvascular determines the viability of the posterior fl ap transfer should be considered only fl ap is whether the gluteus maximus is left when use of local fl aps is contraindicated. attached to the fl ap. In this case, adequate However, the use of free fl aps is often re- blood supply to the gluteus maximus and stricted as a result of the limited availabil- the posterior fl ap is provided from branches ity of recipient vessels.97 12A entering the gluteus maximus at its sacral origin; these branches derive from the mid- COMPLICATIONS dle sacral, iliolumbar, and other arteries Initially, overall complications in sar- independent of the blood supply provided coma patients after pelvic resections were by the internal iliac vessels.23,35,106 Tumor reported in 75% of patients, with 25% to contamination, previous surgery, or tumor 35% having a 5-year survival rate. More arising from the gluteus muscle preclude recently, overall complications rates have the use of the posterior gluteus maximus decreased to Ͻ2%, the 5-year survival myocutaneous fl ap.98 rate increased to 37%, and the local re- 12B The anterior thigh fl ap is a modifi ed currence rate and perioperative mortality Figure 12: Standard hemipelvectomy uses the version of the posterior gluteus maxi- have decreased to 17% and almost 0%, posterior gluteus maximus myocutaneous fl ap, mus myocutaneous fl ap that has allowed respectively.* The most common compli- which is swung anteriorly to close the wound (ar- rows: gluteus maximus muscle; arrow head: sciatic for the treatment of diffi cult buttock and cations were intraoperative hemorrhage; nerve; asterisk: femoral neurovascular bundle) (A). pelvic tumors in which the posterior fl ap sciatic and femoral nerve injuries on the Wound closure following internal hemipelvectomy was involved or contaminated by a tu- opposite side; ureter, bladder, and bowel with the posterior gluteus maximus myocutaneous mor.36 The anterior thigh fl ap consists of injuries; wound-healing complications; fl ap (B). skin, subcutaneous fat, and the quadri- infection and dislocation of prostheses; ceps muscle. With the quadriceps femoris infection and fracture of allografts; lower- The transabdominal rectus abdominus muscle attached to the fl ap, the dominant quadrant hernia; bowel ischemia; and late musculocutaneous fl ap has become a main- blood supply is provided through the lat- venous thrombosis.† Sacrectomies have stay in the closure of large sacral defects. eral femoral circumfl ex branches of the been associated with wound complica- The advantages of the fl ap are its abundant deep femoral artery.35,107 Although the tions requiring fl ap closure, mechanical supply of well-vascularized tissue, reliabil- superfi cial femoral vessels may provide instability requiring spinopelvic recon- ity, versatility, and the simplicity of dissec- additional blood supply when they can struction and fusion, stress fractures, and tion.100-102 Some authors reported the use of be preserved, their presence is not neces- long-term neurological defi cits.42,46,117-122 the opposite fl ap to reduce complications.98 sary for the viability of the anterior thigh Patients with sacral resections dis- In patients with anterior abdominal osto- fl ap.35 This fl ap cannot be used in patients tal to S3 generally have limited defi cits, mies, this fl ap is often unavailable.97 with tumor contamination of the anterior with preservation of sphincter function Standard hemipelvectomy uses the thigh compartment. in the majority and some reduced peri- posterior gluteus maximus myocutaneous The medial thigh adductor myocu- neal sensation and sexual ability. The fl ap, which is swung anteriorly to close taneous fl ap is an option for hemipel- highest variability in functional results is the wound (Figure 12).35,103 One of its vectomy closure in patients with tumors seen for transverse resections above S3. problems is the development of skin fl ap involving the buttock and anterolateral Preserving both S1 nerve roots is impor- necrosis.35,104,105 A common perception is upper thigh.99,108 Another option is the tant for normal gait and foot plantarfl ex- that skin fl ap necrosis of the posterior fl ap axial thigh fi llet fl ap, which is based on ion. Sectioning of the S1 roots may result depends on the level of ligation of the iliac the spare parts concept that uses residual in clinically relevant motor defi cits (walk- vessels. According to this perception, the tissue from amputated limbs for complex ing with external support), and almost blood supply of the posterior fl ap is better soft tissue reconstructions, thereby limit- uniformly results in total loss of sphincter when ligation is performed at the external ing donor-site morbidity by not further in- control and sexual ability. Unilateral re- iliac vessels because the gluteal arteries volving healthy structures.109-111 The free section of sacral roots leads to unilateral that provide the main vascular supply to fi llet lower leg fl ap is a free fl ap raised the gluteus maximus muscle originate from the calf and is supported by the pop- *References 3,6,7,11,12,14,17,18,28,37,114. from the internal iliac vessels.35 liteal artery anastomosed to the cut end of †References 12,14,28,40,74-76,82,106,115,116.

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defi cits in strength and sensitivity; how- 2. Shin KH, Rougraff BT, Simon MA. 17. Langlais F, Lambotte JC, Thomazeau H. Oncologic outcomes of primary bone sarco- Long-term results of hemipelvis reconstruc- ever, sphincter control may be either pre- mas of the pelvis. Clin Orthop Rel Res. 1994; tion with allografts. Clin Orthop Relat Res. served or only partially compromised.41,52 304:207-217. 2001; 388:178-186. Patients with bilaterally preserved S2 3. Kawai A, Huvos AG, Meyers PA, Healey JH. 18. Miles WK, Chang DW, Kroll SS, et al. roots will retain bowel and bladder func- Osteosarcoma of the pelvis: oncologic results Reconstruction of large sacral defects fol- of 40 patients. Clin Orthop Relat Res. 1998; lowing total sacrectomy. Plast Reconstr Surg. tion; in those patients in whom only 1 348:196-207. 2000; 105:2387-2394. S2 root is preserved, bowel and bladder 4. Ozaki T, Flege S, Kevric M, et al. 19. Pollock RC, Skinner JA, Blunn GW, Pringle function will likely be lost. Patients with Osteosarcoma of the pelvis: experience of JA, Briggs TW, Cannon SR. The swing pro- the Cooperative Osteosarcoma Study Group. cedure for pelvic ring reconstruction follow- resection of 1 to all 4 S2 and S3 roots J Clin Oncol. 2003; 21(2):334-341. ing tumour excision. Eur J Surg Oncol. 2003; have saddle anesthesia and signifi cant re- 5. Kawai A, Healey JH, Boland PJ, et al. 29:59-63. duction in sphincter control.41,50 Prognostic factors for patients with sarcomas of 20. Enneking WF. The anatomic considerations Reconstruction procedures have in- the pelvic bones. Cancer. 1998; 82:851-859. in tumor surgery: pelvis. In: Enneking WF, ed. Musculoskeletal Tumor Surgery. vol. 2. New creased the rates of infection and me- 6. Baratti D, Gronchi A, Pennacchioli E, et al. Chordoma: natural history and results in 28 York, NY: Churchill Livingstone. 1983:483-529. chanical complications because of the patients treated at a single institution. Ann 21. Sanders G. Lower Limb Amputations. A lengthy surgical procedure and the poorly Surg Oncol. 2003; 10:291-296. Guide to Rehabilitation. Philadelphia, PA: vascularized residual region. Despite 7. Court C, Bosca L, Le Cesne A, Nordin JY, F.A. Davis; 1986. technological advances, reconstructions Missenard G. Surgical excision of bone sar- 22. Enneking WF (ed). Limb Salvage in comas involving the sacroiliac joint. Clin Musculoskeletal Oncology. New York, NY: using pelvic prostheses have been asso- Orthop Relat Res. 2006; 451:189-194. Churchill Livingstone; 1987. ciated with complication rates as high as 8. Sar C, Eralp L. Surgical treatment of primary 23. Karakousis CP, Emrich LJ, Driscoll DL. 60%, with 40% of patients needing у1 tumors of the sacrum. Arch Orthop Trauma Variants of hemipelvectomy and their com- repeat surgeries.14,74-76,81,82,84 Following Surg. 2002; 122:148-155. plications. Am J Surg. 1989; 158(5):404-408. sacroiliac resection and spinopelvic re- 9. Dickey ID, Hugate RR Jr, Fuchs B, 24. 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Iliofemoral arthrodesis Malawer MM. Reconstruction using the sad- 12 and pseudarthrosis: a long-term functional dle prosthesis following excision of primary by a psychiatric specialist. outcome evaluation. Clin Orthop Relat Res. and metastatic periacetabular tumors. Clin 2002; (397):29-35. Orthop Relat Res. 1995; (314):203-213. CONCLUSION 12. Fuchs B, Yaszemski MJ, Sim FH. Combined 27. Windhager R, Karner J, Kutschera HP, The use of limb-salvage pelvic resec- posterior pelvis and lumbar spine resection Polterauer P, Salzer-Kuntschik M, Kotz R. for sarcoma. Clin Orthop Relat Res. 2002; Limb salvage in periacetabular sarcomas: tions has increased with the advances in (397):12-18. review of 21 consecutive cases. Clin Orthop Relat Res imaging and surgical techniques and in- 13. Gokaslan ZL, Romsdahl MM, Kroll SS, et al. . 1996; (331):265-276. strumentation. However, pelvic surgery Total sacrectomy and Galveston L-rod recon- 28. 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FEBRUARY 2012 | Volume 35 • Number 2 e243