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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 e232 ORTHOPEDICS | ORTHOSuperSite.com PELVIC RESECTIONS | MAVROGENIS ET AL 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 FEBRUARY 2012 | Volume 35 • Number 2 e233 ■ Feature Article 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
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