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Surgical Oncology 20 (2011) e215ee221

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Surgical Oncology

journal homepage: www.elsevier .com/locate/suronc

Review

Anterior thigh flap extended hemipelvectomy and spinoiliac arthrodesisq

Andreas F. Mavrogenis a, Konstantinos Soultanis a, Pavlos Patapis b, Panayiotis J. Papagelopoulos a,*

a First Department of Orthopaedics, Attikon University Hospital, Athens University Medical School, 41 Ventouri Street, 15562 Holargos, Athens, GreecebDepartment of Surgery, Attikon University Hospital, Athens University Medical School, Athens, Greece

a r t i c l e i n f o

Article history:Accepted 6 July 2011

Keywords:Extended hemipelvectomySpinoiliac arthrodesisAnterior thigh flap

q Investigation performed at Athens University Me* Corresponding author. Tel./fax: þ30 210 6843426

E-mail addresses: pjp@hol.gr, pjportho@otenet.gr

0960-7404/$ e see front matter � 2011 Elsevier Ltd.doi:10.1016/j.suronc.2011.07.001

a b s t r a c t

We present the technique of anterior thigh flap extended external hemipelvectomy with spinoiliacarthrodesis in treatment of the patient with recurrent low-grade pelvic chondrosarcoma extending to thelower lumbar spine. Extended hemipelvectomy involves skeletal resection beyond the standard hemi-pelvectomy that is the SI joint by removal of contiguous musculoskeletal structures, such as elements ofthe sacral and lumbar spine or contralateral pelvic bone, in addition to the affected innominate bone.Spinoiliac arthrodesis reestablishes spinopelvic stability; the anterior thigh musculocutaneous flapprovides reliable well-vascularized soft tissue coverage. This technique may serve an important role inthe surgical management of patients with low-grade pelvic malignancies.

� 2011 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e215Operative procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e216

Preoperative planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e216Anterior approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e216Anterior thigh flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e216Tumor resection e extended hemipelvectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e216Reconstruction e spinoiliac arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e217Postoperative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e218

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e218Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e220Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e220Financial disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e220Authorship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e220References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .e220

Introduction

Pelvic resections have been classified to facilitate consistentdiscussions into three types: type I (iliac), type II (periacetabular)and type III resection (obturator) [1]. Resections involving thesacrum are referred as type IV. Resections that include the proximalfemur are referred as type H, and classified into type H1 (femoralhead), type H2 (pertrochanteric area) and type H3 (subtrochanteric

dical School, Athens, Greece..(P.J. Papagelopoulos).

All rights reserved.

area) [1,2]. Combined resections are referred by combining therespective numbers [3]. Standard hemipelvectomy involvesremoval of the entire innominate bone from the pubic symphysisthrough the sacroiliac joint, along with (external hemipelvectomy)or without (internal hemipelvectomy) amputation of the ipsilaterallimb [2,4,5]. Compound hemipelvectomy involves removal of thecontiguous visceral pelvic structures, irrespective of the extent ofskeletal resection or design of soft tissue coverage [6]. The specific

A.F. Mavrogenis et al. / Surgical Oncology 20 (2011) e215ee221e216

type of pelvic resection to be carried out depends on the areainvolved and the extent of the tumor [1e3,7e9].

Particular problems arise when the tumor involves the sacrumand the lower lumbar spine [7,10e13]. In these cases, to obtainacceptable surgical margins, skeletal resection should extendbeyond the standard hemipelvectomy that is the SI joint, and mayinclude the ilium, the entire or part of the sacrum and part of thelower spine; this procedure is defined as extended hemi-pelvectomy, with (external hemipelvectomy) or without (internalhemipelvectomy) amputation of the limb [4,14]. The term extendedhemipelvectomy implies removal of contiguous musculoskeletalstructures, such as elements of the sacral and lumbar spine orcontralateral pelvic bone, in addition to the affected innominatebone [6,15]. Major spinopelvic resections have been further classi-fied in four types: type 1 (total sacrectomy), type 2 (hemi-sacrectomy), and type 3 and 4 resections (partial and totalsacretomies in conjunction with external hemipelvectomy) [9].

The literature consists of scant data on extended hemipelvectomy[4e6,14e18]. The development of instability and spinal deformity, andneed for primary or secondary spinoiliac fusion after this operation iscontroversial [5,15,19,20]. In the case of external hemipelvectomycoupled with hemisacrectomy, if the majority of the lumbosacralarticulation is resected, patients likely benefit from instrumented spi-noiliac fusion. However, in the case of total sacrectomy external hemi-pelvectomy it is necessary to provide reconstruction by spinoiliacarthrodesis between the remaining lumbar spine and remaining hem-ipelvis and limb [3e5,9,14,21,22]. Depending on the degree of theresection of the various anatomic structures in and around the lumbo-sacral area including the intervertebral discs, middle spinal column,facets, iliolumbar ligament and paraspinal muscles [23], the destabi-lizing effect becomes more profound with subsequent pelvic obliquityand secondary scoliosis [15]. Routine spinal fixation is not warranted attheendof theprimaryresectionbecauseof the lowoverallprevalenceofsymptomatic scoliosis requiring stabilization, the high morbidity andmortality rate after extended hemipelvectomy, interference of theimplants with subsequent imaging for oncological follow-up of thepatients, and ability to perform secondary fixation/fusion for painfulinstability if necessary [15]. However, since the overall prevalence ofsymptomatic scoliosis after extendedhemipelvectomy is relatively highin the subset of longer-term survivors, spinoiliac stabilization may bejustified at first stage [15]. Traditional wound closure following hemi-pelvectomies included the use of the posterior gluteus maximus flap[24]. However, for the treatment of difficult buttock and pelvic tumorswhere the posterior flap was involved and/or contaminated by tumor,alternative wound closure techniques such as the anterior thigh flapshould be used for reliable well-vascularized soft tissue coverage [24].

In this article, we present the technique of anteriorflap extendedexternal hemipelvectomywith spinoiliac arthrodesis in treatmentofthe patient with recurrent low-grade pelvic chondrosarcomaextending to the lower lumbar spine, aiming to revisit this fairlycomplex oncologic procedure and present its technical details.

Operative procedure

Preoperative planning

Following histological confirmation of diagnosis, the extent ofthe tumor needs to be assessed by imaging (Fig. 1), neurologic, andendoscopic evaluation in multidisciplinary settings.

Anterior approach

Under general anesthesia, in the supine position, through themidline approach to the abdomen, the aorto-iliac segment ismobilized by ligating all small lumbar branches. The ipsilateral and

sometimes bilateral internal iliac vessels need to be ligated(Fig. 2A). Then, anterior L4eL5 discectomy is performed (Fig. 2B).The colon is mobilized from the presacral tumor mass anda colostomy is performed. Colostomy in the event of removal of therectum, and ileal conduit for total cystectomy must be carefullyplanned. Colostomy is not always necessary, and it can always bedone secondarily; generally it is better to stay out of the perito-neum, if possible. If necessary depending on the tumor extent andinvolvement of the rectum, it is critical to bring ostomy through theipsilateral rectus muscle and keep contralateral rectus muscleintact. This will preserve blood supply of the vertical rectusabdominis musculocutaneous (VRAM) flap, which may becomevery important in dealing with wound complications that are verycommon. The position of the colostomy should also take account ofthe eventual prosthesis; in this setting, it may be better on thecontralateral side. In the present patient, a descending or sigmoidcolostomy was done on the left lower abdomen. The anteriorwound is closed and the patient is repositioned in the oppositelateral decubitus position for preparation of the anterior thigh flapand tumor resection.

Anterior thigh flap

A posterolateral thigh incision extending up to the lumbar spineand distally to just superior to the metaphyseal flare of the femur isperformed. The blood supply of the anterior thigh flap is primarilybased on the descending branch of the lateral circumflex femoralartery. The center of the flap is located over the course of thecommon and superficial femoral vessels. The distal end of the flap isdesigned at the level of the adductor hiatus utilizing the vastmajority of the quadriceps femoris muscle and overlying skin sothat the flap could reach the level of the umbilicus. Followingincision of the fascia covering the superficial femoral vessels, thesevessels are ligated and divided just above their passing through theadductor hiatus. The quadriceps muscle is divided distally to thesurface of the femur and is stripped off the entire length of bone.Dissection is then carried out on the deep surface of the superficialfemoral vessels until the profunda femoris vessels are encountered.The profunda vessels are divided as they pass between pectineusand adductor longus muscles, and the medial circumflex vessels asthey pass between the psoas major and adductor longus muscles.The proximal part of the profunda vessels and their lateralcircumflex branches are preservedwith the flap [25]. The dissectionis then taken around the medial aspect of the thigh through theadductors’ compartment and up through the perineum. Part of thesartorius is preserved; the remainder of the adductor compartmentis left behind. The anterior thigh flap is then swung superiorly andanteriorly and laid carefully on a support. The femoral nerve isprotected throughout the course of dissection such that the flapwill be sensate for the patient.

Tumor resection e extended hemipelvectomy

The dissection is taken posteriorly along the opposite side of thesacrum to the lumbar spine. The sacrospinous and sacrotuberousligaments are incised along with the origin of the gluteus maximusmuscle. The opposite sciatic nerve is identified and protected, andthe perineal and rectal tissues are elevated from the sacrum ante-riorly. Finally, the dissection is taken from posterior to anterioralong the ipsilateral iliac crest. The L4eL5 disc space is verifiedusing fluoroscopy, and L4eL5 laminectomies are performed; theopposite L5 and S1 nerve roots are preserved, while the ipsilateralL5 and S1 nerve roots, and the dural tube are double tied. Then, theposterior spinal dissection is taken around to the front at the L4eL5disk space, and the opposite sacroiliac joint is incised to separate

Figure 1. (A) Axial computed tomography of the pelvis of a 30-year-old woman with a recurrent grade I chondrosarcoma of the right hemipelvis shows osteolysis of the right iliacbone and the sacrum, and a large soft-tissue mass. (B) Coronal (left) and axial (right) T2-weighted magnetic resonance imaging of the pelvis show the recurrent tumor extendingfrom the right posterior hemipelvis to the sacrum and the L5 vertebra. Smaller lesions are observed at the right buttock and gluteal muscles at the level of the hip joint.

A.F. Mavrogenis et al. / Surgical Oncology 20 (2011) e215ee221 e217

the sacrum from the opposite hemipelvis. After this dissection, thetumor specimen including the limb and innominate bone, thesacrum and the L5 vertebra is removed en bloc (Fig. 3A). The distalfemur from the amputated limb can be removed from the specimenand saved sterilely for the reconstruction (Fig. 3B).

Reconstruction e spinoiliac arthrodesis

The L2eL4 pedicles are prepared for pedicle screws bilaterally.The undersurface of the L4 vertebral body is cleared of cartilageand annulus tissue, and the left iliac wing is exposed by raisingthe gluteus muscle from the outer table and the iliacus musclefrom the inner table. The ilium is externally rotated so that theL4 vertebra comes near and the distance between the supra-acetabular region and the L4 vertebra decreases, and theremaining lumbar spine is centralized over the remaining pelvissuch that the patient’s center of gravity is relatively uniform. It isoften necessary to perform a foraminotomy of the lowest one ortwo lumbar segments remaining to avoid too much traction onthe lumbar nerve roots to the remaining leg from this maneuver.

Figure 2. Through the anterior midline approach to the abdomen (A) mobilization of the ccectomy was done.

Two polyaxial 7.5-mm screws are inserted to the ilium (Fig. 4A)and connected with rods placed in the pedicle screws (Fig. 4B).The upper iliac screw is connected through an independent rodto the left-sided spinal rod by rod connectors. The right-sidedspinal rod is bent to travel from the right-sided pedicle screwsin L2, 3, and 4 into the distal iliac screw. One cross connector isplaced at the level of the upper L4 vertebra between the left andright rods (Fig. 4C).

Providing a robust autograft strut between the lowestremaining vertebral body and the hemipelvis is paramount. Asupracondylar distal femoral osteotomy is done to the amputatedfemur and the femoral condyles after adequate preparation arepositioned at the L4-ilium arthrodesis, and fixed with two long6.5-mm cancellous screws with washers (Fig. 4D). The transverseprocesses of L2, L3, and L4 bilaterally, and both tables of the leftilium are decorticated. The femoral head and proximal femur canbe used as autologous bone grafting at the site of the spinoiliacarthrodesis. Allograft bone may also be used. Suction drains areplaced into the pelvis and the wound is closed with the anteriorthigh flap.

ommon, external and internal iliac vessels and the colon, and (B) anterior L4eL5 dis-

A.F. Mavrogenis et al. / Surgical Oncology 20 (2011) e215ee221e218

Postoperative management

Physical therapy begins on the second postoperative dayincluding respiratory exercises, passive-assisted range of motion ofthe hip and knee joints and active range of motion exercises of theupper extremities. A thermoplastic lumbo-pelvic orthosis is rec-ommended for 3 months. Partial weight-bearing is started 10weeks after the operation, and weight-bearing progressivelyadvances to full with muscle strengthening exercises (Fig. 5).

Discussion

The goals of extended hemipelvectomy with spinoiliacarthrodesis are to achieve negative-margin tumor resection andpelvic reconstruction with maximum postoperative stability andfunctional single leg gait [2,22]. Surgical goals include stabilizationof the pelvis and improved function [3,4,14,21]. The surgicaloutcomes directly depend on the extent of tumor involvement andsurgical resection. The functional results depend on the mechanicalstability of the construct. Considering the high failure rates and theincreased morbidity, this type of operation is not indicated forpatients with metastatic disease at onset [3,4,14,21]. Extendedhemipelvectomy in a patient who had prior resections at the samesite carries an increased risk for complications and local recurrence[2,5]. In this article, we present the technique of anterior flapextended external hemipelvectomy with spinoiliac arthrodesis intreatment of the patient with recurrent low-grade pelvic chon-drosarcoma extending to the lower lumbar spine. By using thistechnique, wide-margin resection was achieved without intra-operative or postoperative complications; the anterior muscu-locutaneous thigh flap provided reliable well-vascularized softtissue coverage; stability of the construct was observed at the 24-month follow-up without evidence of local recurrence.

There is ongoing debate whether to do external or internalhemipelvectomy for pelvic tumors [2,4,5,21,26]. Comparing theoncological outcome of patients having an extended internalhemipelvectomy with patients having an extended external hem-ipelvectomy, the incidence of complications was lower withamputation of the limb, and the patients recover more quickly afterexternal hemipelvectomy than after the most limited pelvicresections [2,4,5]. In decision making, internal hemipelvectomyshould at least lead to the same tumor-free margins as amputationand provide superior functional outcome with acceptable

Figure 3. (A) The left L5 and S1 nerve roots were preserved; the right L5 and S1 nerve rootinnominate bone, the sacrum and the L5 vertebra was removed en bloc. The distal femur w

morbidity [21,26]. Yet, even if the surgical margins are the same,there is more limited area at risk for recurrence with externalcompared to internal hemipelvectomy. Moreover, external hemi-pelvectomy is recommended in patients with tumor recurrence,sacral involvement and extension into the sciatic notch [2,4,5].

With the evolution of surgical techniques and neo-adjuvanttreatments the ability to resect tumors of the posterior pelviswith adequate margins has advanced greatly. However, recon-struction of the large resultant defects remains in evolution[5,11e13,27e29]. Spinal fixation using hooks, Luque wires, pediclescrews, and the LuqueeGalveston iliac fixation have fueled theevolution of reconstruction techniques [5,11,13,28]. Althoughimproved fixation to the pelvis, proximal fixation still was tenuousand stability was difficult to achieve. The current generation ofinstrumentation used in spinopelvic reconstruction is the pediclescrew-rod construct. The fixation is more rigid than that of previousconstructs, however, long-term follow-up is not available [5,22].

In the past, the defects created by these procedures were closedprimarily, resulting in wounds subjected to considerable tensionand high rates of complications such as wound dehiscence,hematoma, flap necrosis and infection. To overcome these prob-lems, pedicled or free musculocutaneous flaps have been used forwound closure, and Gore-Tex mesh and acellular dermal matricesto repair retroperitoneal defects and prevent hernias [25,30e32].The VRAM flap has also become a mainstay in the closure of largesacral defects, because of its abundant supply of well-vascularizedtissue, reliability, versatility, and simplicity of dissection [33e35].Some authors suggested the use of the opposite flap to reducecomplications [31]. In patients with anterior abdominal ostomiesthis flap is often unavailable [30]. Standard hemipelvectomy makesuse of the posterior gluteusmaximusmusculocutaneous flap that istransferred anteriorly to close the wound [25,36]. Necrosis of theposterior flap depends on the level of ligation of the iliac vessels.Common iliac vessel ligation has been significantly associated witha 2.7-fold increase in flap necrosis rate compared to external iliacvessels ligation in patients undergoing posterior flap hemi-pelvectomy [6]. The blood supply of the posterior flap is betterwhen ligation is performed at the external iliac vessels since thegluteal arteries that provide themain vascular supply to the gluteusmaximus muscle originate from the internal iliac vessels[6,19,25,37]. However, regardless of the level of ligation of the iliacvessels the factor that determines viability of the posterior flap iswhether the gluteus maximus is left attached to the flap, which

s, and the dural tube were double tied. (B) The specimen including the right limb andas cut (arrow) and saved sterile for the reconstruction.

Figure 4. (A) Two polyaxial 7.5-mm screws were inserted to the left ilium. (B) Transpedicular screws were inserted to the L2eL4 pedicles bilaterally, and connected with rods. Theupper iliac screw was connected through an independent rod to the left-sided spinal rod by rod connectors. (C) One cross connector was placed at the level of the upper L4 vertebrabetween the left and right rods. (D) The femoral condyles of the amputated femur were positioned at the L4-ilium arthrodesis and fixed with two long 6.5-mm cancellous screwswith washers.

A.F. Mavrogenis et al. / Surgical Oncology 20 (2011) e215ee221 e219

then provides adequate blood supply to the posterior flap,regardless of the level of ligation of the iliac vessels [25]. In thiscase, adequate blood supply to the gluteus maximus and theposterior flap is provided from branches entering the gluteusmaximus at its sacral origin; these branches derive from themiddlesacral, iliolumbar, and other arteries independent of the bloodsupply provided by the internal iliac vessels [8,25,38]. The anteriormusculocutaneous thigh flap provides reliable well-vascularizedsoft tissue coverage when the posterior flap was involved orcontaminated by tumor or previous surgery [24], and removal ofthe gluteus muscle was oncologically necessary [6,25]. It consists ofskin, subcutaneous fat, and the quadriceps femoris muscle [31]. Asmuch as needed of the anterior thigh compartment may be saved,depending on the size of the defect. Although the superficialfemoral vessels may provide additional blood supply when theycan be preserved, their presence is not necessary for the viability ofthe anterior thigh flap, since the dominant blood supply is through

Figure 5. At 24 months postoperatively, two dimensional (left) and three-dimensional (righ

the lateral femoral circumflex branches of the profunda femorisartery [8,25,39]. The risk of postoperative infection is also reduced[39]. Moreover, patients who are expected to require postoperativeradiation therapy should be considered for the anterior thigh flapsince the well-vascularized musculocutaneous flap tolerates radi-ation well [39]. Obviously, this flap cannot be used in patients withtumor contamination of the anterior thigh compartment. Themedial thigh adductor musculocutaneous flap is an option forhemipelvectomy closure in patients with tumors involving thebuttock and anterolateral upper thigh [32,40]. Another option is theaxial thigh fillet flap, which is based on the “spare parts” conceptthat uses residual tissue from amputated limbs for soft tissuereconstructions, thereby limiting donor site morbidity by notfurther involving healthy structures [41e44]. The free fillet lowerleg flap is a free flap raised from the calf, and supported by thepopliteal artery anastomosed to the cut end of the internal iliacartery in end-to-end fashion [42e44]. Use of free microvascular

t) computed tomography scan show a stable construct and healing of the arthrodesis.

A.F. Mavrogenis et al. / Surgical Oncology 20 (2011) e215ee221e220

flaps is often restricted as a result of the limited availability ofrecipient vessels; these flaps should be considered only when useof local flaps is contraindicated [30].

Extended hemipelvectomy with spinopelvic arthrodesis istechnically demanding and fraught with potential complications[2,5,8,26,39,45e50]. Initially, a 75% overall morbidity and highmortality has been reported after hemipelvectomy. More recently,the overall morbidity reduced to 54% and the perioperativemortality to 5% [6]. With better patient selection improvements in5-year survival were observed. Tumors’ histology and stage havea deciding impact on the patient outcome and risk of developingdistant metastasis. Reconstructive procedures aim to decrease rateof infections, flap necroses, and skeletal instability. However, themorbidity of hemipelvectomy remains high; wound complicationsrates from 14% to 80% andmechanical failures rates from 12% to 27%have been reported [6,8,19,26,37,45e50]. Wound complicationssuch as infection and flap necrosis are the most common; longeroperative time and increased complexity are associatedwith higherwound infection and flap necrosis rates [6]. Wound complicationsrequire aggressive debridement in the operating room and some-times flap reconstruction; in this setting, the anterior muscu-locutaneous thigh flap provides reliable well-vascularized softtissue coverage. If the traditional hemipelvectomy flaps fail, theVRAM flap may be the lifeboat flap for hemipelvectomy salvage.Other reported complications include intraoperative hemorrhage,nerve and visceral injuries of the ureter, bladder and bowel, lowerquadrant hernia and resection of an ischemic terminal ileum [2,5],late venous thrombosis that typically involves the common iliacvein [2], and psychological effects and depression [5].

Conclusion

The presented herein technique may serve an important role inthe surgical management of patients with low-grade pelvicmalignancies. Extended hemipelvectomy provides for wide tumorresection; spinoiliac arthrodesis in the same or second stage rees-tablishes spinopelvic stability. The anterior hemipelvectomy flapprovides superior reconstruction for the extended hemipelvectomypatients.

Conflict of interest statementNone of the authors had any financial or personal relationships

with other people or organizations that could inappropriatelyinfluence (bias) their work.

Financial disclosureNone of the authors had any funding source in support of this

study.

Authorship

Study concepts: Andreas F. Mavrogenis, Konstantinos Soultanis,Pavlos Patapis, Panayiotis J. Papagelopoulos

Study design: Andreas F. Mavrogenis, Panayiotis J.Papagelopoulos

Data acquisition: Andreas F. Mavrogenis, Konstantinos Soulta-nis, Pavlos Patapis, Panayiotis J. Papagelopoulos

Quality control of data and algorithms: Andreas F. Mavrogenis,Konstantinos Soultanis, Pavlos Patapis, Panayiotis J. Papagelopoulos

Data analysis and interpretation: Andreas F. Mavrogenis, Kon-stantinos Soultanis, Pavlos Patapis, Panayiotis J. Papagelopoulos

Statistical analysis: NoManuscript preparation: Andreas F. Mavrogenis, Panayiotis J.

Papagelopoulos

Manuscript editing: Andreas F. Mavrogenis, Konstantinos Soul-tanis, Pavlos Patapis, Panayiotis J. Papagelopoulos

Manuscript review: Andreas F. Mavrogenis, Konstantinos Soul-tanis, Pavlos Patapis, Panayiotis J. Papagelopoulos

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