Keywords
osteosarcoma - hemipelvectomy - fibula flap
Introduction
Major pelvic resections for malignant tumors of the pelvic ring are infrequent, extensive
surgical procedures with relatively high incidence of postoperative complications
and significant mortality.[1] Hemipelvectomies are classified as internal or external depending on the preservation
or amputation of the lower limb, respectively. Complication rates are high in both
types.[2]
[3] The case of internal hemipelvectomies reconstruction depends on the extent of the
resection and overall prognosis of the patient, with a remarkable lack of consensus
about the need of bone reconstruction and the optimal reconstructive technique if
performed.
Incisional hernia is an uncommonly reported postoperative complication of hemipelvectomies,
and most reported cases refer to external hemipelvectomies in the form of hernia of
the pelvic stump.[4]
[5]
[6]
[7] Few cases of incisional hernia have been reported after internal hemipelvectomy
probably because most cases are asymptomatic or overshadowed by more serious complications.[8]
A case of late complex hypogastric and femoral incisional hernia after extended hemipelvectomy
for recurrent osteosarcoma treated with distal abdominal wall fixation into a free
fibula flap is reported. To the best of the authors’ knowledge, no similar technique
has been described previously in the English literature.
Case Report
A 32-year-old male patient presented with a recurrent osteosarcoma of the left innominate
bone after two previous attempts at local resection. The tumor was 13 cm in diameter,
affecting the left iliac and pubic bones, acetabulum, adductor compartment through
the obturator canal, left ureter, urinary bladder, left spermatic cord, and prostate
([Fig. 1]). The tumor was resected including all affected structures through an extended internal
hemipelvectomy. The left femoral vein was resected and bypassed with a greater saphenous
graft. The femoral artery and the femoral nerve were preserved. Prostate, partial
bladder, and partial sigma resection were performed, and a left-to- right transureter
ureterostomy reestablished the left urinary way. The left testes and cavernous corpus
were also resected. The left lower abdominal wall was reinforced with a polypropylene
mesh and a femoroiliac arthrodesis was performed with 4.5-mm reconstruction plates.
Histological clear margins were obtained. During the early postoperative period, three
abdominal revisions due to recurrent uroperitoneum were needed with left cutaneous
ureterostomy.
Fig. 1 Extent of the recurrent osteosarcoma of the left hemipelvis, with infiltration of
the adductor compartment, prostate, urine bladder, and sigma.
One year postoperative, a bladder augmentation procedure was performed with an ileocystoplasty
with left ureter reinsertion, without complications.
Six years after the index surgery, with no evidence of tumor progression, the patient
complained of a large hypogastric incisional hernia with abdominal contents herniating
to the adductor and femoral regions. The lack of bone in the left pelvic ring precluded
anchoring the left lower abdominal wall into a solid structure ([Fig. 2]).
Fig. 2 Postoperative X-ray with iliofemoral arthrodesis. No load-bearing issues in the daily
walking.
A free fibula flap was harvested from the right side and used, with one osteotomy,
to reconstruct the iliopubic continuity, caudal to the femoral vessels and femoral
nerve. Bone fixation was performed with 3.5 mm locking reconstruction plates and the
flap pedicle was anastomosed to the right femoral artery and greater saphenous vein
through a single-stage vascular loop ([Figs. 3]
[4]). Four months later, once the bone consolidation was solid enough, the lower abdominal
wall was reinserted using multiple bone suture anchors to the fibula ([Fig. 5]). The postoperative course was uneventful with correction of the hernia. At the
time, the patient is alive, active, in complete oncological remission and with a competent
abdominal wall ([Video 1]). Erectile dysfunction and fixed hip extension are the only complaints of the patient.
Fig. 3 A right free fibula osteocutaneous flap was used to reconstruct the pelvic rim. Anastomoses
were performed to the right femoral vessels through a vascular loop with the greater
saphenous vein. Locking 3.5-mm reconstruction plates were used for fixation.
Fig. 4 X-ray of the bone reconstruction, prior to abdominal wall anchoring.
Fig. 5 Multiple heavy polyester sutures were fixed to the consolidated free fibula flap,
respecting the passage of the femoral nerve and the femoral vessels.
Discussion
Internal hemipelvectomy for malignant tumor resection is a major surgical procedure
with potential severe complications and nonnegligible mortality. Osseous reconstruction
using double barreled free fibula flaps has been reported with good long-term results,
although the need for osseous reconstruction of the pelvic rim after internal hemipelvectomy
for load transmission is still a subject of debate.[9]
[10]
Abdominal wall complications are rarely reported after internal hemipelvectomy.[8] In standard anterior hemipelvectomies, there is enough muscular mass in the adductor
compartment to allow for a solid repair of the lower abdominal wall and inferior (adductor
or femoral) hernias are uncommon. In the case presented herein, the extent of resection
included the adductor compartment resulting in a weaker-than-desired repair of the
pelvic floor, despite the use of polypropylene mesh. The lack of a solid structure
to suture the incompetent inferior abdominal wall raised the need for delayed bone
reconstruction of the anterolateral pelvis. Load bearing through the left iliofemoral
arthrodesis allowed the patient asymptomatic daily walking without further bone reconstruction.
The indication for skeletal pelvic ring reconstruction in this case was not for load
transmission but to provide a solid structure for abdominal wall anchoring. The contralateral
fibula flap was ideal in terms of length, cross-section, and healing potential in
an irradiated area. Staging the reconstruction allowing the bone to heal before multiple
drill holes and bone anchors were placed and a high-tensioned abdominal wall repair
was performed seemed logical from biological and mechanical standpoints.
Conclusion
The reconstruction could have been performed earlier, at the time of the hemipelvectomy,
but the amount of surgical insult in an extended internal hemipelvectomy is massive
and adding a free flap increases morbidity and potential postoperative systemic complications.
The possibility of a massive adductor and femoral abdominal incisional hernia was
not foreseen, due to the rarity of this complication. Multiple abdominal revisions
in the early postoperative period may have contributed to the poor quality of the
abdominal wall healing.
Video 1
The patient performing Valsalva maneuvers, showing a competent abdominal wall. Online
content including video sequences viewable at: www.thieme-connect.com/products/ejournals/html/10.1055/s-0040-1709378.
