Reconstruction after external hemipelvectomy using tibia-hindfoot rotationplasty with calcaneo-sacral fixation
© Kong et al; licensee BioMed Central Ltd. 2008
Received: 25 October 2007
Accepted: 21 January 2008
Published: 21 January 2008
External hemipelvectomy is associated with high post operative morbidity and a poor functional outcome. We aim to explore a reconstruction technique to improve function and post operative appearance for patients who undergo external hemipelvectomy.
We present a Case where extensive cancer involvement of pelvis and femur was managed with a novel surgical technique, which involved a calf sparing modified anterior flap hemipelvectomy combined with rotationplasty of the spared calf and fixation of calcaneus to the sacrum, thereby recreating a new thigh stump.
Tibia-hindfoot rotationplasty result in good functional outcome and appearance for selected patients undergoing external hemipelvectomy with unaffected external iliac and femoral vessels.
Despite the advent of increasingly effective chemotherapy and limb-salvage surgery, external hemipelvectomy may remain the only surgical treatment for extensive tumors arising from the hip or pelvis. It is also a potential life-saving procedure for patients with massive pelvic trauma and uncontrollable sepsis of the lower limb. Unfortunately, external hemipelvectomy is often associated with high morbidity and poor quality of life for patients. Postoperative appearance following conventional external hemipelvectomy is also often poor, resulting in body image issues.
We here present a novel reconstructive technique aiming to improve function and appearance for patients requiring external hemipelvectomy. This technique is applicable in selected patient with unaffected external iliac and femoral vessels (i.e. most patients who would otherwise qualify for an anterior flap hemipelvectomy). The reconstruction involves a modified anterior flap hemipelvectomy with resection of the femur and hemipelvis but preservation of below knee structures. The calf with its vascular supply is rotated by 180 degrees. The fore- and mid-foot are then resected. The calcaneus is then fixed to the osteotomy site at the sacrum, thereby recreating a new thigh stump.
Dissection at the level of pelvis and proximal thigh was performed with the aim to preserve the calf. Briefly, deep dissection commenced proximal to the iliac crest, where the abdominal wall musculature was divided. The internal aspect of the iliac muscle and the sacroiliac joint were dissected, thereby dividing the sacral plexus.
A musculocutaneous anterior thigh flap comprising quadriceps and parts of the adductor compartment was then elevated based superficially. Along the medial thigh incision, the superficial femoral artery and vein were identified at the level of the adductor canal underneath the sartorius muscle and the vessels were skeletonized distally into the popliteal fossa keeping the blood supply to both heads of the gastrocnemius intact to for the basis of a filleted musculoskeletal calf flap. The tibial nerve and the common peroneal nerve were divided at this level. The knee joint was then disarticulated and the patella resected. The musculocutaneous thigh flap is further developed by elevating the quadriceps muscles and adductor muscles from the femur. The muscular flap, which is in continuity with the calf (superficial femoral and popliteal vessels and saphenous nerve intact), is then retracted anteriorly to allow adequate access to the hip and pelvis. The adductors are detached from the pubis and the symphysis is divided.
From posterior, the medial origin of the gluteus maximus was elevated from the sacrum. An osteotomy was performed through sacrum from the greater sciatic notch laterally to approximately 1 cm medial to the sacroiliac joint. Ileo-lumbar, sacro-tuberal and sacro-spinal ligaments are divided. Under external rotation of the hemipelvis, the hemipelvis, tumour mass and femur were delivered en-bloc.
Preparation of rotational flap
The rotational tibia-hindfoot flap was supplied by the superficial femoral artery and vein. A skin incision was made from the lateral end of the popliteal crease parallel to the fibula down to the posterior aspect of the lateral malleolus. A fillet flap consisting of superficial posterior muscle compartment and overlying skin was developed from the lateral calf incision (vascularized by perforators through the soleus and gastrocnemius muscles). A fillet flap of the foot was made based on the dosalis pedis pedicle dorsally and the posterior tibial pedicle medially. The ankle and subtalar joints were preserved. The osseous forefoot was amputated through the transverse tarsal joint (Chopart).
Post Operative Course
Wide resection remains an important principle in the treatment of bone and soft tissue sarcomas. Despite the fact that the majority of patients with pelvic sarcomas can be safely treated with chemotherapy and limb-salvage surgery,  in a number of patients external hemipelvectomy is still required to achieve wide margins. Techniques used for soft tissue coverage following external hemipelvectomy include the posterior flap and the anterior flap closure [3, 4]. These techniques aim to achieve tissue coverage but is often associated with high morbidity and poor functional outcomes [5, 6]. Post operatively the majority of patients are either unable to ambulate without the use of crutches (80%) or remaining wheelchair bound or bed bound (15%); only around 5% of patients are eventually able to ambulate with prosthesis . Well-fitted prosthesis for post-external hemipelvectomy patients is difficult to produce and the energy requirement to ambulate with prosthesis is very high. For patients who had external hemipelvectomy even the ability to sit upright can be difficult without a well-fitted sitting socket because of the lack of an ischium. Psychological issues surrounding body image following external hemipelvectomy is also significant and requires extensive pre and pos operative counseling .
Reconstructive surgery in our Case involved the combination of external hemipelvectomy with a rotation tibia-hindfoot flap resulting in the fixation of calcaneus to the ileosacral osteotomy. The calcaneus tubercle functions as a neo-ischium and the tibia-hindfoot flap functions as a neo-thigh. This allows the patient to sit upright without the aid of a sitting socket. Cosmetically, the surgery results in an apparent above knee stump.
Peterson et al had previously described two cases of tibia-hindfoot rotationplasty with calcaneopelvic arthrodesis for infective complications involving the proximal femur. In both cases no parts of the bony pelvis had been resected and the calcaneus could be fixed to the acetabulum. Movement was allowed as a result of retained tibiotalar and subtalar joints. Post operatively these patients were able to tolerate full weight bear with the use of a standard above knee amputation prosthesis . Similar tibial turn-up procedure to manage distal femoral bone loss has also been described in pediatric patients with good functional result [10, 11]. The surgical resection in our Case was much more extensive, with the removal of entire hemi-pelvis and femur. Despite this the patient in our Case has made excellent recovery with good sitting function and cosmetically satisfactory result.
The Case illustrates that the use of the novel technique of tibia-hindfoot rotationplasty can result in good functional outcome and appearance for selected patients undergoing external hemipelvectomy with unaffected external iliac and femoral vessels.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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