In posterior flap hemipelvectomy, preservation of the gluteus maximus with the flap guarantees its viability regardless of the level of ligation of the iliac vessels. In anterior flap hemipelvectomy with the quadriceps femoris attached to the flap, the dominant blood supply is through the lateral femoral circumflex branches of the profunda vessels, which is sufficient to maintain the flap.Hemipelvectomy is performed usually for malignant tumors not resectable through more conservative operations. The term implies the resection of the lower extremity en bloc with the ipsilateral hemipelvis. Whenever a portion of the posterior iliac bone and the corresponding iliac crest have been preserved, the term conservative hemipelvectomyis used. The most common procedure is the posterior flap hemipelvectomy in which a posterior flap is used to cover the resulting defect. One of the problems with posterior flap hemipelvectomy is the development of flap necrosis, which, according to Douglass et al,occurs in 80% of the patients, requiring debridement in about 50%. In an article by Higinbotham et al,the rate of skin flap necrosis was 26%, but approximately 75% of patients developed wound problems and 7% died postoperatively. Posterior flap hemipelvectomy is usually performed for tumors of the iliac fossa or groin in which the posterior flap is not close to or involved with the tumor. A common perception is that skin flap necrosis of the posterior flap is dependent on the level of ligation of the iliac vessels. According to this perception, the blood supply of the posterior flap is better when the ligation of vessels is at the external iliac level. The level of vessel ligation depends on the cephalad extent of the tumor.In our previous experience, the incidence of flap necrosis of the posterior flap was not different between patients who had ligation of the external iliac vessels compared with those who had ligation of the common iliac vessels. The factor that determines viability of the posterior flap is whether the gluteus maximus is left attached to the flap, which then provides adequate blood supply to the posterior flap, regardless of the level of ligation of the iliac vessels. In this experience, posterior flap necrosis occurred in 4 (10%) of 39 hemipelvectomies with ligation of the common iliac vessels and 3 (14%) of 21 hemipelvectomies with ligation of the external iliac vessels, while this complication occurred in 6 of 10 patients with a fasciocutaneous posterior flap, consisting of skin and subcutaneous fat, and in 1 (2%) of 50 patients (the common iliac vessels were divided in 35 patients) with a myocutaneous posterior flap, consisting of skin, subcutaneous fat, and gluteus maximus.There is apparently sufficient blood supply to the gluteus maximus and to the posterior flap from branches entering the gluteus maximus at its sacral origin. These branches derive from the middle sacral, iliolumbar, and other arteries independent of the blood supply provided by the internal iliac vessels. The histological findings of the tumors treated with posterior flap hemipelvectomy in the period 1973 to 1994 are shown in Table 1.Histological Findings of Tumors of 60 Posterior Flap HemipelvectomiesFindingNo. of PatientsBone tumorsChondrosarcoma5Osteosarcoma5Soft tissue tumorsMalignant fibrous histiocytoma8Liposarcoma6Rhabdomyosarcoma5Synovial sarcoma4Neurofibrosarcoma4Fibrosarcoma2Leiomyosarcoma2Round cell sarcoma1Desmoid tumor1Giant neurofibroma1Squamous cell carcinoma10Malignant melanoma6The anterior flap hemipelvectomy is less commonly practiced, and it is applicable to tumors of the buttock that are not resectable through a more conservative operation. Occasionally, as Frey et alhave reported, an anterior flap hemipelvectomy may be required for advanced osteomyelitis of the pelvis due to decubitus ulcers in the buttock not treatable with a more conservative approach. Pack and coworkersinitially reported a technique using an extremely short anterior flap, excluding any underlying muscles with a segment of femoral vessels attached to the flap for about 4 to 5 cm in length. Later, Mnaymneh and Templeelaborated further on the technique of a long anterior myocutaneous flap, including the quadriceps muscle and its blood supply. Sugarbaker and Chretienalso described the procedure of anterior flap hemipelvectomy, consisting of a myocutaneous flap of quadriceps femoris muscle. In these descriptions of the anterior flap hemipelvectomy procedure, general reference is made to the femoral vessels as providers of the blood supply of this flap without further specification.In the article by Sugarbaker and Chretien,it was stated that the superficial femoral artery is preserved to sustain the myocutaneous flap. In our initial experience with anterior flap hemipelvectomy, the center of the anterior flap was located over the course of the common and superficial femoral vessels and the flap itself consisted of skin, subcutaneous fat, and fascia, a portion of sartorius muscle, and the superficial femoral and common femoral vessels in their continuity with the external iliac vessels.In this approach, the distal end of the flap was at the level of the adductor hiatus and, following incision of the fascia covering the superficial femoral vessels, these vessels were ligated and divided just above their passing through the adductor hiatus. Dissection was then carried out on the deep surface of the superficial femoral vessels until the profunda vessels were encountered, which were ligated and divided at their origin from the common femoral vessels. The common femoral vessels were further mobilized to provide the necessary mobility to the anterior flap. In our initial experience with 3 patients, the flap remained viable; however, this was a fairly narrow flap and it is hard to ascertain whether a wider flap would have survived. Since the current publications about anterior flap hemipelvectomy based on the quadriceps musculature and its blood supply were indicative of a wider and sturdier flap, the subsequent number of cases of anterior flap hemipelvectomy that we performed included the quadriceps muscle as well as the common and superficial femoral vessels, the latter being ligated at the inferior end of the flap.In this technique, a broad anterior flap is made over the quadriceps and the course of femoral vessels. The lower end of the flap is just above the patella. The superficial femoral vessels are divided at the level of the adductor hiatus. The quadriceps muscle is divided distally to the surface of the femur and is stripped off the entire length of bone (Figure 1), leaving behind on the specimen the posterior portion of the vastus medialis and vastus lateralis. The profunda vessels are divided as they pass between pectineus and adductor longus, and the medial circumflex vessels as they pass between the psoas major and adductor longus. In this type of dissection, the proximal part of the profunda vessels and their lateral circumflex branches are preserved with the flap (Figure 2).Figure 1.Specimen of an anterior flap hemipelvectomy for a chondrosarcoma of the pelvis extending into the buttock, showing that the quadriceps has been stripped off the anterior aspect of the femur.Figure 2.The anterior flap after removal of the specimen of Figure 1.In our experience with anterior compartment resections of the thigh for soft tissue sarcomas,it was clear that the main blood supply to the quadriceps was deriving from the lateral femoral circumflex vessels (Figure 3). In a recent case, it was possible to demonstrate that the viability of the anterior flap can be preserved through the common femoral and lateral femoral circumflex branches of the profunda vessels without any contribution from the superficial femoral vessels.Figure 3.The specimen of an anterior compartment of the right thigh, including a soft tissue sarcoma, has been mobilized, tethered only by its nerve and blood supply, ie, the lateral femoral circumflex vessels prior to their ligation and division.REPORT OF A CASEThis patient had a history of chronic osteomyelitis in the area of the right hip with sinus tracts leading to the groin a few centimeters below the inguinal ligament, as well as a large area of ulceration and necrosis of the right ischial tuberosity due to long-standing paraplegia after spinal injury. X-ray films had demonstrated involvement and destruction of the right hip joint through osteomyelitis (Figure 4). In the past, the patient had been treated several times with debridement of that area and intravenous antibiotics and had been admitted to the Veterans Affairs Hospital several times in the last 3 years for this condition. In the last admission, he was admitted to the emergency department due to bleeding from an ulcerated sinus tract area in the right groin with a hemoglobin value of 57 g/L and hematocrit of 0.18. He was resuscitated successfully and angiography revealed a bleeding point in the right superficial femoral artery near its takeoff from the common femoral artery. This artery was embolized with 2 coils to control the bleeding. Subsequently, the patient continued to ooze from the same area. Following consultation with infectious disease and orthopedic surgeons, they agreed to proceed with a right hemipelvectomy.Figure 4.x-Ray films show evidence of chronic osteomyelitis.With the patient in a semilateral position on the operating table, it was clear that a posterior flap was not available due to extensive necrosis and ulceration of the lower half of the right buttock. A routine anterior flap was not available again because of extensive inflammatory changes and ulceration in the area of the right groin below the level of the inguinal ligament. Therefore, the incision was started in the proximal portion of the right buttock, carried around the area of the necrosis, and down on the lateral aspect of the thigh to just above the patella and then medially over the vastus medialis in a cephalad direction lateral to the area of fistulization of the groin skin toward the anterior superior iliac spine. This flap consisted of a rather narrow bridge of skin and subcutaneous tissue, proximally, which broadened distally and included the quadriceps femoris. After the deep fascia was incised, the rectus femoris and vastus intermedius were divided down to the surface of the femur distally above the patella. The vastus lateralis was divided near its insertion to the linea aspera and, medially, the anterior half of the vastus medialis was preserved with the flap. The dissection was carried lateral to the superficial femoral vessels to the area above the fistulization of the skin of the groin, and then the superficial femoral vessels were ligated and divided at their origin from the common femoral vessels. The vastus muscles were dissected off their femoral origin, the tendon of rectus femoris was divided off the anteroinferior iliac spine, the continuation of the profunda femoris vessels was divided as these vessels passed between pectineus and adductor longus and the medial circumflex vessels as they passed between the insertion of iliopsoas and pectineus muscles. The anterolateral abdominal wall muscles were divided off the iliac crest, the inguinal ligament was divided at the anterior superior iliac spine, the femoral nerve was ligated and divided, and then dissection was continued behind the external iliac vessels. The inguinal ligament was also divided at the pubic tubercle, and the right rectus abdominis muscle was divided off the pubic crest. The peritoneum was dissected superiorly. Branches of the external iliac vessels were ligated and divided to allow posterolateral mobility and then the iliopsoas muscle was divided at the proximal portion of the iliac bone. The greater sciatic notch was exposed medially and laterally, and the iliac bone was divided with a Gigli saw. Medially, the pubic symphysis was divided, permitting the removal of the specimen after division of the sacrospinous and sacrotuberous ligaments laterally, and the ipsilateral levator ani medially.The patient's recovery was uneventful, and he was discharged home on the 15th day after the surgery with a healing incision and a viable flap (Figure 5). One year later, he remains well.Figure 5.Anterior flap healing satisfactorily with the proximal bridge of skin based laterally, and the main body of the flap sustained by the quadriceps muscle and its blood supply.COMMENTAnterior flap hemipelvectomy has been based on a long and wide anterior flap centered over the quadriceps and the femoral vessels, which provide its blood supply. However, in the past, it has not been differentiated as to what vessels may provide adequate blood supply to this extensive flap. In some of the previous reports, it has been presumed that the superficial femoral vessels were crucial in providing blood supply to the anterior flap. However, in the anterior flap, which includes the quadriceps femoris, the lateral femoral circumflex branches of the profunda vessels provide the main blood supply to this muscle and, therefore, it appears logical that these vessels would provide sufficient blood supply to the flap without the complementary participation of the superficial femoral vessels. In our patient, the superficial femoral artery near its takeoff had been eroded through the process of osteomyelitis in this patient with paraplegia and already had been embolized with coils by the radiologist. The proximal portion of the flap had to be made narrower and placed more laterally because of extensive necrosis in the posterior buttock as well as in the area of the skin below the groin with fistulization from chronic osteomyelitis. The anterior flap developed in the patient was based on blood supply from the iliac vessels, and their continuation into common femoral and lateral femoral circumflex branches while the superficial femoral vessels were ligated close to their origin. This is a modification of anterior flap hemipelvectomy, which may prove useful in similar rare cases. However, the main interest of the case presented is that it proves that the blood supply to the quadriceps through the lateral femoral circumflex branches is sufficient to provide adequate vascularization for an anterior flap. Although the superficial femoral vessels may provide additional blood supply when they can be preserved, their presence is not necessary for the viability of an anterior flap. In developing an anterior flap, which includes the quadriceps, the dissection should be carried out in front of the femur laterally and the surface of adductor muscles medially (dividing the continuation of profunda vessels and medial femoral circumflex branches at the point of their entry into the adductors), which preserves the proximal portion of the profunda vessels and the lateral femoral circumflex branches supplying the quadriceps and the rest of the flap.HODouglassMRazackDHolyokeHemipelvectomy.Arch Surg.1975;110:82-85.NLHiginbothamRCMarcovePCassonHemipelvectomy: a clinical study of 100 cases with five-year follow-up on 60 patients.Surgery.1966;59:706-708.JPApffelstaedtDLDriscollJESpellmanAFVelezJFGibbsCPKarakousisComplications and outcome of external hemipelvectomy in the management of pelvic tumors.Ann Surg Oncol.1996;3:304-309.DFreyLSMatthewsHBenjaminWJFidlerA new technique for hemipelvectomy.Surg Gynecol Obstet.1976;143:753-756.GTPackTFMillerIMArielHemipelvectomy.In: Pack GT, Ariel IM, eds. Treatment of Cancer and Allied Diseases. Vol. 8. 2nd ed. New York, NY: Harper & Row; 1964:284-307.WMnaymnehWTempleModified hemipelvectomy utilizing a long vascular myocutaneous thigh flap.J Bone Joint Surg.1980;62A:1013-1015.PHSugarbakerPAChretienAnterior flap hemipelvectomy.In: Nicholson TH, Sugarbaker PH, eds. Atlas of Extremity Sarcoma Surgery. Philadelphia, Pa: JB Lippincott; 1984:67-88.CPKarakousisMPVezeridisVariants of hemipelvectomy.Am J Surg.1983;145:273-277.CPKarakousisKKontzoglouDLDriscollAnterior compartment resection of the thigh in soft tissue sarcomas.Eur J Surg Oncol.1998;24:308-312.Corresponding author and reprints: Constantine P. Karakousis, MD, PhD, Department of Surgery, Millard Fillmore Hospital, 3 Gates Cir, Buffalo, NY 14209 (e-mail: firstname.lastname@example.org).
JAMA Surgery – American Medical Association
Published: Jul 1, 2001