Vertical rectus abdominis musculocutaneous flow-through flap to a free fibula flap for total sacrectomy reconstruction

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  • VERTICAL RECTUS ABDOMINIS MUSCULOCUTANEOUS FLOW-THROUGH FLAP TO A FREE FIBULA FLAP FOR TOTALSACRECTOMY RECONSTRUCTION

    PATRICK B. GARVEY, M.D.,1* MARK W. CLEMENS, M.D.,1 LAURENCE D. RHINES, M.D.,2 and JUSTIN M. SACKS, M.D.3

    Purpose: The purpose of this report of a small series was to describe the technique of total sacrectomy reconstruction using a pedicledvertical rectus abdominis musculocutaneous (VRAM) ow-through ap anastomosed to a free bula ap. Methods: We reviewed all con-secutive total sacrectomy reconstructions performed from 2009 to 2011. Surgical technique and patient outcomes were assessed. Results:Total sacrectomy reconstructions included three two-stage and three-stage VRAM ow-through ap to free bula ap patients all of whichambulated by discharge. Flap survival was 100%. Pelvic ring defects were reconstructed with A-frame bula ap struts anastomosed tothe distal epigastric vessels of pedicled trans-pelvic VRAM aps. Complications such as wound healing, infection or hardware failure werenot observed. Bony union occurred at an average 2.7 6 0.6 months. Conclusions: Total sacrectomy reconstruction using a VRAM ow-through ap anastomosed to a two-strut free bular ap allows initial assessment of the recipient vessels during the rst and ensuing oper-ative stages, satises the bone and soft tissue requirements of the defect, and provides a durable, functionally optimized reconstruction.VVC 2012 Wiley Periodicals, Inc. Microsurgery 00:000000, 2012.

    Sacral neoplasms are rare. The most common neoplasiasrequiring sacrectomy are chordomas, which constitute

    14% of all primary malignant bone tumors.1 Oncologic

    management of primary sacral malignancies typically

    entails en bloc, wide local excision of the tumor, necessi-

    tating either a partial or total sacrectomy. Total sacrec-

    tomy is a disabling resection that creates a massive tissue

    defect and causes complete disjunction of the lumbar

    spine from the pelvis. Since the lumbosacral and sacroil-

    iac joints are critical for maintaining stability between the

    spine and pelvis, their removal makes reconstruction of

    this region essential for ambulation and weight bearing.2

    An optimal surgical technique for total sacrectomy

    reconstruction has not yet been determined. Traditional

    methods of spino-pelvic stabilization include some form

    of lumbo-iliac instrumentation, alloplastic tibia bone

    grafts, and a trans-sacral pedicled vertical rectus abdomi-

    nis musculocutaneous (VRAM) ap for soft tissue recon-

    struction.36 Although this strategy does provide durable

    soft tissue reconstruction of the total sacrectomy wound,

    the use of large, non-vascularized, alloplastic tibia bone

    grafts results in unacceptable rates of incomplete arthrod-

    esis and eventual hardware failure. In comparison to non-

    vascularized alloplastic bone grafts, vascularized bula

    bone aps have been shown in other applications to pro-

    vide 40% more strength, 56% more stiffness, higher

    complete arthrodesis rates, and superior functional

    outcomes.711 However, studies describing an efcient,

    predictable, and safe strategy for reconstructing the total

    sacrectomy defect with vascularized bone aps are

    lacking.3,7

    The purpose of this report of this small series was to

    describe this new technique and determine whether this

    approach is safe for total sacrectomy reconstruction with

    respect to patient outcomes and donor site morbidity.

    PATIENTS AND METHODS

    We reviewed the outcomes of the three patients who

    underwent total sacrectomy reconstruction with a pedicled

    VRAM ow through ap to a free bula ap at our insti-

    tution between January 1, 2009 and December 31, 2011.

    Data were collected from a prospectively entered depart-

    mental database and patients medical records. We

    recorded patient demographic, reconstruction, and out-

    comes data. The MD Anderson Cancer Center Institu-

    tional Review Board granted approval for the study.

    Our neurosurgeons stabilized patient defects with

    spinopelvic instrumentation using rod xation between

    lumbar pedicle screws and iliac screws. Soft tissue defects

    were reconstructed with pedicled transpelvic VRAM aps.

    The two-strut free bula to pedicled transpelvic VRAM

    ow-through ap provided bony stabilization between the

    lumbar spine and iliac bones.

    Surgical Techniques

    A brief description of the stages of this total sacrec-

    tomy reconstruction follows. Stage 1 was performed with

    the patient in the supine position. The plastic surgeon

    began the operation by making an anterior laparotomy

    incision, protecting the medial perforators of the pedicled

    1Department of Plastic Surgery, The University of Texas, MD Anderson Can-cer Center, Houston, TX2Department of Neurosurgery, The University of Texas, MD Anderson CancerCenter, Houston, TX3Department of Plastic and Reconstructive Surgery, The Johns HopkinsSchool of Medicine, Baltimore, MD

    *Correspondence to: Patrick B. Garvey, M.D., Department of Plastic Surgery,Unit 1488, The University of Texas, MD Anderson Cancer Center, 1400Pressler, Houston, TX 77030. E-mail: pbgarvey@mdanderson.org

    Received 16 September 2011; Revision accepted 27 February 2012;Accepted 2 March 2012

    Published online in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.21990

    VVC 2012 Wiley Periodicals, Inc.

  • VRAM ap. The colorectal surgeon mobilized the rectum

    from the underlying sacrum. A vascular surgeon mobi-

    lized and ligated the internal iliac vessels to devascularize

    the sacrum. While the extirpative team completed these

    maneuvers, the plastic surgeon dissected the bone-only

    bula ap, leaving the ap pedicled on the peroneal ves-

    sels. For optimal orientation of the distal VRAM recipi-

    ent vessels for the bula ap pedicle, the bula ipsilateral

    to the pedicled VRAM was dissected. The plastic surgeon

    also dissected the saphenous vein below the knee, ligating

    side branches, for interposition vein grafting and leaving it

    in continuity for later retrieval in the prone position during

    Stage 3. After the neurosurgeons mobilized the lumbosac-

    ral nerve trunks and initiated the anterior sacroiliac osteoto-

    mies and the L5/S1 anterior diskectomy, threadwire saws

    wrapped with cotton pledgets were left in the pelvis for

    later retrieval during Stage 2 to facilitate completion of the

    sacroiliac osteotomies. The plastic surgeon then temporar-

    ily closed the bula and saphenous vein graft donor sites

    with staples and completed harvest of the pedicled VRAM

    ap. It was not necessary to divide the insertion of the rec-

    tus abdominis muscle from the pubic ramus. The ap could

    reach the sacrectomy defect easily with the insertion intact,

    and leaving the insertion avoided inadvertent twisting of

    the pedicle during transpelvic delivery of the pedicled

    VRAM ap into the sacrectomy wound. Care was taken to

    adequately divide the posterior rectus sheath and perito-

    neum to avoid kinking of the vascular pedicle during later

    ap retrieval and inset. The distal end of the pedicled

    VRAM ap was temporarily sutured to the sacral promen-

    tory to facilitate ap retrieval during Stage 2. The pedicled

    VRAM ap was placed in the pelvis, and the laparotomy

    incision was primarily closed with unilateral component

    separation to minimize tension on the closure.12 At the

    plastic surgeons discretion, prosthetic mesh was inlayed

    into the rectus sheath to reinforce the pedicled VRAM ap

    donor site. The patient was then extubated and transferred

    back to a hospital room to remain on bedrest until Stage 2

    was completed within the next 35 days.

    Stage 2 was performed with the patient in the prone

    position to allow for a posterior approach to the sacrum.

    During this stage, the neurosurgeon made a posterior

    incision extending from the superior gluteal cleft to the

    base of the spine. The gluteus and piriformis muscles, as

    well as the sacrotuberous and sacrospinous ligaments,

    were divided. The coccygectomy and mobilization of the

    lower rectum were performed using a Kraske approach.13

    After an L5 laminectomy was performed, the thecal sac

    containing the S1S5 sacral nerve roots were ligated and

    divided. This facilitated completion of the posterior L5/

    S1 diskectomy. Finally, the previously placed threadwire

    saws were retrieved and the sacroiliac osteotomies were

    completed. The sacrum was then resected en-bloc and

    lumbo-pelvic instrumental stabilization was achieved.

    It was our experience that Stage 2 was typically asso-

    ciated with prolonged anesthesia time, signicant blood

    loss, and the use of multiple units of transfused blood

    products, which caused the patient to become hypocoagu-

    able and hemodynamically labile. For this reason, the

    free bula harvest and microvascular anastomosis was

    delayed in two of the three cases until a third stage to

    allow time for the patient to be resuscitated and stabilized

    in the intensive care unit. If the patient were deemed to

    be hemodynamically stable, the free bula ap could

    have been harvested and inset (see Stage 3) during Stage

    2. Stage 2 was completed by the plastic surgeon, who

    delivered the VRAM ap into the sacrectomy defect and

    used it to temporarily close the wound.

    Once the patient was adequately stabilized in the in-

    tensive care unit (911 days in our experience), the

    patient was returned to the operating room for Stage 3.

    First, the sacrectomy wound was re-explored and the

    bony defect exposed deep to the pedicled VRAM ap.

    The plastic surgeon created an osteotomy in the middle

    of the bula ap that was the length required to span the

    distance (as measured by the neurosurgeon) from the

    base of the body of the fth lumbar vertebra to the ilia

    above the sciatic notches. The neurosurgeon used a cut-

    ting burr to fashion a convexity in the inferior endplate

    of the L5 body to receive the apex of the two-strut bula

    bipod and convexities in the bilateral ilia to receive the

    distal and proximal ends of the free bula ap. The bula

    ap was harvested and inset between the L5 body and

    the ilia above the sciatic notches using lag screw xation.

    The distal branches of the deep inferior epigastric arteries

    (DIEA) were dissected from the rectus abdominis muscle

    of the pedicled VRAM in preparation for anastomosis to

    the peroneal vessels. Microvascular anastomoses were

    then fashioned between the peroneal artery and the distal

    branches of the inferior epigastric artery of the pedicled

    trans-sacral VRAM. The position of the recipient vessels

    on the pedicled VRAM was supercial in the sacrectomy

    defect due to the position of the pedicled VRAM, which

    facilitated a straightforward execution of the anastomoses.

    In two of the three patients presented here, a short,

  • exion and sitting were avoided for 2 months postopera-

    tively. Sitting protocols involved progressive time inter-

    vals of alternating 5-min buttock pressure for 1 month.

    All three patients transitioned to outpatient rehabilitation

    by 3 months postoperatively, where they ultimately pro-

    gressed to unassisted full ambulation.

    RESULTS

    The most common indication for sacrectomy was

    chordoma, followed by osteosarcoma (Table 1). The aver-

    age age of the patients was 45 6 9.4 years. One patientreceived preoperative pelvic radiotherapy. The average

    follow-up time for the three total sacrectomy patients was

    8.4 months. The average length of hospitalization was 79

    days. All of the vascularized two-strut free bula to

    VRAM ow-through ap patients progressed to ambula-

    tion with a walker by the time of hospital discharge and

    were ambulating, with occasional use of a cane, after

    outpatient rehabilitation. Stable arthrodesis of the bula

    ap was conrmed in all three patients an average of 3

    months postoperatively using computed tomography

    scans. Unfortunately, the rst patient developed dissemi-

    nated metastatic osteosarcoma and died 5 months after

    surgery, which precluded conrmation of long term fol-

    low-up of the free bula ap with delayed repeat pelvic

    imaging. At 2 years after surgery, the second patient

    remains free of recurrence, lives independently, has

    returned to work, and ambulates with the occasional aid

    of a cane. The third patient began ambulation with the

    aid of a cane at 6 weeks postoperatively and also remains

    free of recurrence.

    Case Report

    A 53-year-old male presented with left inguinal, peri-

    neum, and lower extremity numbness. MRI demonstrated

    a mass involving nearly the entire sacrum. Biopsy of the

    mass conrmed a sacral chordoma. The rst stage of a

    planned two-stage resection and reconstruction occurred

    as described above. Three days later, Stage 2 was com-

    pleted from the prone position and included completion

    of the en bloc total sacrectomy (Fig. 1). Massive bleeding

    necessitated ligation of the internal iliac vessels, tempo-

    rary wound closure with the VRAM ap, and deferral of

    the free bula harvest and inset until the patient could be

    stabilized in the ICU. Eleven days later, the patient was

    returned to the operating room for harvest and insetting

    of the free bula to the pedicled VRAM ap (Fig. 2).

    The patient was discharged after a 2-month hospitaliza-

    tion. Postoperative surveillance CT scans at 3 and 9

    months conrmed arthrodesis of the bula ap to the

    lumbar spine and iliac bones (Fig. 3). As of 1 1/2 years

    after his surgery, he was able to ambulate unassisted,

    Table

    1.Patient,Reconstruction,andOutcomesCharacteristics

    Patient

    Age

    BMI

    Preop

    XRT

    Preop

    chemo

    Tumortype

    Postop

    XRT

    Postop

    Chemo

    Useof

    vein

    grafts

    Stages

    Days

    between

    Stages

    1and2

    Days

    between

    Stages

    2and3

    Hospital

    discharge

    (months)

    Tim

    eto

    fusion

    (months)

    Ambulatory

    statusat

    discharge

    Oncologic

    outcome

    Follow-up

    (months)

    121

    28

    Yes

    Yes

    Osteosarcoma

    Yes

    Yes

    Yes

    33

    92.3

    2.2

    Unassisted6

    cane

    Deceased

    after

    recurrence

    4.9

    253

    29

    No

    No

    Chordoma

    No

    No

    Yes

    33

    11

    2.1

    3.6

    Unassisted6

    cane

    Norecurrence

    16.7

    358

    26

    No

    Yes

    Chordoma

    No

    No

    No

    25

    NA

    3.4

    2.2

    Unassisted6

    cane

    Norecurrence

    3.5

    BMI,bodymassindex;XRT,radiationtherapy.

    Fibula to VRAM for Sacrectomy 3

    Microsurgery DOI 10.1002/micr

  • drive an automobile, return to full-time employment, and

    reported occasionally jogging for exercise.

    DISCUSSION

    In this report, we describe a reproducible technique

    for total sacrectomy reconstruction that appears to opti-

    Figure 1. (a) Appearance of the total sacrectomy defect during

    Stage 2 after en-bloc resection of the sacrum and sacral malig-

    nancy and placement of spino-pelvic instrumental stabilization. The

    distal end of the transpelvic VRAM ap, which was not yet deliv-

    ered into the extirpative defect, was in the base of the wound,

    superior to the posterior surface of the rectum. (b) Appearance of

    the surgical site after delivery of the transpelvic VRAM ap and

    temporary ap inset at the conclusion of Stage 2. (c) Computed to-

    mographic appearance of total sacrectomy defect between Stages

    2 and 3 before placement of the two-strut free bula ap. [Color g-

    ure can be viewed in the online issue which is available at wiley

    onlinelibrary.com.]

    Figure 2. Intra-operative appearance of the anastomoses between

    the peroneal vessels of the free bula ap (arrow) and the distal in-

    ferior epigastrics of the transpelvic VRAM ap. Visualization...

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