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Vascularized Femur Flap for Stabilization after Combined Total Sacrectomy and External Hemipelvectomy

2012; Lippincott Williams & Wilkins; Volume: 129; Issue: 5 Linguagem: Inglês

10.1097/prs.0b013e31824aa045

1529-4242

Christopher A. Campbell, David W. Chang,

Sarcoma Diagnosis and Treatment

Sir:FigurePelvic tumors often require wide local en bloc resection, such as a total sacrectomy or a hemipelvectomy. However, combination of these two resections destabilizes the pelvic girdle by removing a substantial portion of the pelvic ring and the base of the spine, and creates a substantial reconstructive challenge.1–4 The reconstitution of the pelvic ring is required to minimize postoperative pain and provide the structural integrity needed to allow ambulation. A 24-year-old man presented with a large right pelvic and sacral osteosarcoma that involved the lumbar spine and paraspinous musculature. The first stage of resection consisted of resection of the left portion of the L5 vertebra through a posterior midline approach and stabilization using pedicle screws and a rod from L2 through the left ilium. The following week, right external hemipelvectomy with leg amputation and total sacrectomy were performed. A vascularized femur flap and a fillet thigh flap were harvested from the amputated leg for immediate reconstruction. A medial longitudinal right thigh incision was made to identify the superficial femoral vessels as they approached the middle third of the femur. The right femur was maintained on its superficial femoral vessel–based pedicle and dissected free from the surrounding musculature in a supraperiosteal plane (Fig. 1). The nutrient vessel could be seen entering the posterior middle third of the femur. The pedicled femur flap was then brought into the pelvis in its native orientation. Rigid fixation of the vascularized femur was performed proximally with two screws to L4 and distally with two screws to the left ilium (Fig. 2). The posterior thigh flap was used as a fillet flap to cover the soft-tissue defect.Fig. 1: A vascularized femur flap based on the superficial femoral vessels.Fig. 2: Rigid fixation of the vascularized femur was performed proximally with two screws to L4 and distally with two screws to the left ilium.L-rod and pedicle screw hardware fixation is typically used in patients who have undergone total sacrectomy and/or translumbar resection.1–4 The additional loss of the entire hemipelvis requires reinforcement of the hardware stabilization to avoid the strain that “pelvic obliquity” can impart on the remaining elements of the pelvic ring.5 Double-barreled fibular strut free flaps have been used previously for reconstitution of the pelvic ring, but these would not have provided the strength or amount of bone necessary for load bearing in our patient.5 For our patient, we were able to use a pedicled femur flap based on the superficial femoral vessels, which were found to give off nutrient vessels at the middle third of the femur. The pedicle extended proximally through the external iliac system with the internal system divided, allowing the femur to reach the lumbar spine without difficulty. In our case, the femur provided a substantial amount of well-vascularized load-bearing bone with excellent strength to reinforce the L-rod and pedicle screw fixation of the lumbar spine to the remaining ilium to allow assisted, pain-free mobility. As we demonstrated, fillet flaps in the form of anterior or posterior myocutaneous flaps can then be used for soft-tissue coverage. Christopher A. Campbell, M.D. David W. Chang, M.D. Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.