Immediate soft-tissue reconstruction using a rectus abdominis myocutaneous flap following wide resection of malignant bone tumours of the pelvis K. Ogura, S. Miyamoto, M. Sakuraba, H. Chuman, T. Fujiwara, A. Kawai From National Cancer Center Hospital, Tokyo, Japan
Resection of malignant bony tumours of the pelvis creates large bone and soft-tissue defects, and is frequently associated with complications such as wound dehiscence and deep infection. We present the results of six patients in whom a rectus abdominis myocutaneous (RAM) flap was used following resection of a malignant tumour of the pelvis. Bony reconstruction was performed using a constrained hip tumour prosthesis in three patients, vascularised fibular graft in two and frozen autograft in one. At a mean follow-up of 63 months (16 to 115), no patients had a problem with the wound. Immediate reconstruction using a RAM flap may be used after resection of a malignant tumour of the pelvis to provide an adequate volume of tissue to eliminate the dead space, cover the exposed bone or implants with well-vascularised soft tissue and to reduce the risk of complications. Cite this article: Bone Joint J 2014;96-B:270–3.
K. Ogura, MD, Orthopaedic Surgeon, Clinical Fellow H. Chuman, MD, Orthopaedic Surgeon, Head T. Fujiwara, MD, Orthopaedic Surgeon, Clinical Fellow National Cancer Center Hospital, Department of Musculoskeletal Oncology, 5-11 Tsukiji, Chuo-ku, Tokyo 1040045, Japan. S. Miyamoto, MD, Plastic Surgeon, Head National Cancer Center Hospital, Department of Plastic and Reconstructive Surgery, 51-1 Tsukiji, Chuo-ku, Tokyo 1040045, Japan. M. Sakuraba, MD, PhD, Plastic Surgeon, Head National Cancer Center Hospital East, Department of Plastic and Reconstructive Surgery, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan. A. Kawai, MD, PhD, Orthopaedic Surgeon, Head National Cancer Center Hospital, Department of Musculoskeletal Oncology 5-11 Tsukiji, Chuo-ku, Tokyo, 1040045, Japan. Correspondence should be sent to Dr A. Kawaie; -mail: [email protected]
©2014 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.96B2. 32514 $2.00 Bone Joint J 2014;96-B:270–3. Received 1 June 2013; Accepted after revision 16 October 2013
Since the 1980s, limb-salvage surgery has been the gold standard for the radical treatment of malignant pelvic tumours or sarcomas of the extremities. The complex anatomy of the pelvis, and the proximity of vessels, nerves and viscera renders the surgery of malignant tumours of the pelvis complicated, particularly as they are often large. 1,2 There is a high rate of complications, such as infection, wound dehiscence, haematoma formation and skin necrosis. 3-8 An overall rate of wound complications of up to 30% to 40% has been reported, and in such cases most patients require a second procedure. 2,5,9-12 These complications lead to delayed post-operative chemotherapy and a poor oncological and functional outcome. 1,2,11,13 Possible reasons for the significantly high rate of complications after pelvic surgery include insufficient soft-tissue cover and a large dead space after wide excision. There is little information about the management of the wound after resection for pelvic tumours, 14-16 and no standardised method of reconstruction has been established. We describe primary soft-tissue reconstruction using a rectus abdominis myocutaneous (RAM) flap following wide resection for malignant tumours of the pelvic bone. Our aim was to clarify whether this procedure reduced the rate of postoperative wound complications.
Patients and Methods This is a retrospective review of 23 patients who underwent surgery for a pelvic sarcoma between 2003 and 2010, including 18 wide resections, three external hemipelvectomies, one curettage and one hip rotationplasty. In six patients we performed immediate soft-tissue reconstruction using a RAM flap, either because of insufficient remaining soft tissue to cover the exposed bone or implants after resection, or the presence of a large dead space or high tension in the wound after primary closure. Data collected comprised the age of the patient at the time of surgery, gender, the size of the tumour and the histological diagnosis. The surgical details included the type of resection, surgical margin, operating time, total blood loss and details of the reconstruction. We noted any adjuvant chemotherapy or radiotherapy, post-operative wound complications (including flap loss or partial necrosis, seroma or haematoma formation and dehiscence), infection and the oncological outcome. We attempted wide resection of the tumour in order to achieve a safe margin, taking care not to damage the deep inferior epigastric vessels. The surgical margin was determined histologically at the point closest to the area resected, and was classified as negative if there was no residual disease or positive if there was microscopic residual disease at the assumed margin. The resection was classified as proposed by Enneking et al.17 THE BONE & JOINT JOURNAL
SOFT-TISSUE RECONSTRUCTION USING A RECTUS ABDOMINIS MYOCUTANEOUS FLAP FOLLOWING WIDE RESECTION OF MALIGNANT BONE
Fig. 1 Diagram illustrating the use of a rectus abdominis myocutaneous (RAM) flap in surgery for the resection of pelvic sarcomas.
Table I. Patient demographics and the detail of treatment Patient/Gender/ Histological diagnosis* Age (yrs)
Follow-up (mths) Resection
1 / M / 33 2 / M / 36 3 / M / 36 4 / F / 33
FVFG FVFG Frozen autograft Constrained hip prosthesis Constrained hip prosthesis Constrained hip prosthesis
115 45 82 89
P1 P1 P2 P1+2
5 / M / 58
Chondrosarcoma Chondrosarcoma MFH of bone Recurrent MFH involving bone Chondrosarcoma
6 / F / 28
Operating time (mins) Blood loss (ml)
715 620 906 580
2400 1300 3300 1300
None None None None
CDF CDF CDF AWD
* MFH, malignant fibrous histiocytoma † FVFG, free vascularised fibular graft ‡ CDF, continuous disease free; AWD, alive with disease; DOD, dead of disease
An ipsilateral or contralateral vertical RAM flap was created (Fig. 1). We usually used an ipsilateral RAM, but a contralateral RAM was used when the ipsilateral deep inferior epigastric vessels were included in the resection (two cases). The vascularised skin flaps were harvested at the maximum size that allowed for primary closure of the donor site. Usually the skin island was elevated in a lateral to medial direction 1 cm to 2 cm distant from the anterior rectus sheath, and the sheath was then incised to expose the rectus abdominis muscle. Part of the anterior rectus sheath, measuring about 3 cm wide, at the level of the umbilicus was attached to the skin island. The deep inferior epigastric vessels at the lateral border of the muscle were dissected as far as the external iliac vessels so as to obtain a long vascular pedicle. The rectus abdominis was then transected at its sternocostal and pubic attachments. In most cases we took the full width of the muscle to obtain a sufficient volume. The musculocutaneous flap and its pedicle, attached only to the deep inferior epigastric vessels, was then transposed to the defect and fixed to the surrounding soft tissue to obliterate VOL. 96-B, No. 2, FEBRUARY 2014
the dead space. The anterior abdominal wall was closed in layers, and drains were placed subcutaneously in the anterior abdominal wall as well as the pelvis.
Results The demographics and details of treatment for these patients are summarised in Table I. None had any pre-operative comorbidity that might have predisposed to wound complications. Negative surgical margins were achieved in all patients. Bony reconstruction was performed using a constrained-type hip tumour prosthesis (Hip Reconstruction Cup; Japan Medical Materials, Osaka, Japan)18 in three patients, a vascularised fibular graft stabilised by pedicle screw fixation in two, and a frozen autograft fixed by plates in one. Five pedicle RAM flaps and one free vascularised RAM flap were used. All of the flaps sufficiently filled the dead space and covered the prosthesis and soft-tissue defects. No significant intra-operative complications occurred. The mean total operating time was 12.4 hours (9.7 to 15.3) and the mean blood loss was 2550 ml (1300 to 3700).
K. OGURA, S. MIYAMOTO, M. SAKURABA, H. CHUMAN, T. FUJIWARA, A. KAWAI
Fig. 2c 17
Figures 2a to 2c – intra-operative photographs of a) Enneking P1+2 resection followed by prosthetic replacement with a constrained total hip system, b) elevation and passing of a vertical RAM flap with an 11 cm by 18 cm skin paddle, and c) successful wound closure. Figure 2d – radiograph at five years post-operatively showing a successful result with no wound complications.
Continuous closed suction drainage and prophylactic antibiotics were used in all patients. The drains were removed after a mean of 11 days post-operatively (6 to 16). The mean post-operative length of antibiotic treatment was 16 days (8 to 34). The wound healed satisfactorily in all patients without infection or dehiscence. None of the patients had any problems with the wound or reconstruction at a mean follow-up of 63 months (16 to 115). The oncological outcomes of the patients at the time of the last follow-up were continuous disease free (CDF) in four, alive with disease (AWD) in one and dead of disease (DOD) in one. Three patients received pre- or post-operative chemotherapy. There was no delay with post-operative chemotherapy in two patients who were scheduled to receive it. No patients received radiotherapy. An example (case 4, Table I) is shown in Figure 2.
Discussion Effective chemotherapy and the development of sophisticated imaging techniques have facilitated limb-salvage
surgery for sarcoma not only of the extremities but also of the pelvic area.19 In spite of these advances, this surgery continues to be associated with a high rate of complications. We recently described 27 patients who underwent resection of pelvic malignancies using prosthetic reconstruction. Wound complications occurred frequently, including infection in ten patients (37%), wound dehiscence in five (19%) and circulation failure in one (4%).10 Several other authors have also recently reported similarly high rates of wound complications following surgery for pelvic tumours.2,5,9,11 In a study of 160 patients who underwent primary closure of the wound following hemipelvectomy, Senchenkov et al12 found that wound complications were the most common causes of post-operative morbidity, including infection in 62 patients (39%) and partial flap necrosis in 41 (26%). In a series of 110 patients after resection for pelvic sarcomas, Hillmann et al2 found that 44 (40%) had wound complications such as infection, skin problems or haematoma formation. THE BONE & JOINT JOURNAL
SOFT-TISSUE RECONSTRUCTION USING A RECTUS ABDOMINIS MYOCUTANEOUS FLAP FOLLOWING WIDE RESECTION OF MALIGNANT BONE
Primary wound closure with high tension and an extensive dead space are inevitably associated with haematoma or seroma formation, predisposing to skin necrosis and infection. A reliable method of reducing these complications in pelvic tumour surgery has long been awaited. Initially, pedicle omentum flaps were used.16 However, they also have associated complications, including ileus requiring laparotomy, and wound hernia.16 The use of gluteus maximus musculocutaneous flaps, thigh fillet flaps or latissimus dorsi myocutaneous flaps has been reported.14,15 A gluteus maximus musculocutaneous flap is seldom useful, as the gluteal vessels are usually sacrificed during resection of pelvic sarcomas.14,15 Recently, the efficacy of a vertical RAM flap in the management of soft-tissue defects in the sacral or perineal region after resection of local tumours has been reported.20-23 Buchel et al21 studied 73 patients with perineal malignancies treated in this way, and found that the rate of complications requiring further surgery was only 3.5%, compared with previously reported rates of 25% to 46%.21 One of the main reasons for the good results seems to be the abundant supply of well-vascularised soft tissue. The RAM flap is versatile. It can be elevated easily and withstands rotation. Certain limitations of this study should be noted. It was retrospective and based on a small number of patients. In addition, the indications for this procedure are limited, making it difficult to accumulate large numbers. The procedure usually takes a long time and the associated increased blood loss requires extensive transfusion, especially in patients who have bone marrow suppression due to pre-operative chemotherapy In conclusion, the aggressive use of soft-tissue reconstruction with well-vascularised tissue has the potential to reduce the risk of complications associated with resection of pelvic malignancies. A RAM flap can provide an adequate volume of tissue to eliminate the dead space, cover any exposed bone or implants, and close the wound without tension. This study was funded by a Grant-in-Aid for Scientific Research from the Ministry of Education and Science (B, No. 22390296), and by the National Cancer Center Research and Development Fund (23-A-10). No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. This article was primary edited by D. Rowley and first-proof edited by J. Scott.
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References 1. Grimer RJ, Carter SR, Tillman RM, et al. Osteosarcoma of the pelvis. J Bone Joint Surg [Br] 1999;81-B:796–802. 2. Hillmann A, Hoffmann C, Gosheger G, et al. Tumors of the pelvis: complications after reconstruction. Arch Orthop Trauma Surg 2003;123:340–344. 3. Fisher NE, Patton JT, Grimer RJ, et al. Ice-cream cone reconstruction of the pelvis: a new type of pelvic replacement: early results. J Bone Joint Surg [Br] 2011;93-B:684– 688. 4. Jeys LM, Kulkarni A, Grimer RJ, et al. Endoprosthetic reconstruction for the treatment of musculoskeletal tumors of the appendicular skeleton and pelvis. J Bone Joint Surg [Am] 2008;90-A:1265–1271. 5. Senchenkov A, Moran SL, Petty PM, et al. Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases. Ann Surg Oncol 2008;15:355–363. 6. Delloye C, Banse X, Brichard B, Docquier PL, Cornu O. Pelvic reconstruction with a structural pelvic allograft after resection of a malignant bone tumor. J Bone Joint Surg [Am] 2007;89-A:579–587. 7. Jansen JA, van de Sande MA, Dijkstra PD. Poor long-term clinical results of saddle prosthesis after resection of periacetabular tumors. Clin Orthop Relat Res 2013;471:324–331. 8. Gebert C, Gosheger G, Winkelmann W. Hip transposition as a universal surgical procedure for periacetabular tumors of the pelvis. J Surg Oncol 2009;99:169–172. 9. Han I, Lee YM, Cho HS, et al. Outcome after surgical treatment of pelvic sarcomas. Clin Orthop Surg 2010;2:160–166. 10. Kikuta K, Kawai A, Morioka H, et al. Clinical outcomes of 27 constrained hip prostheses for reconstruction after resection of malignant pelvic tumors. Procs 17th International Society of Limb Salvage. Hamburg, Germany, 2007. 11. Ozaki T, Hillmann A, Bettin D, Wuisman P, Winkelmann W. High complication rates with pelvic allografts: experience of 22 sarcoma resections. Acta Orthop Scand 1996;67:333–338. 12. Senchenkov A, Moran SL, Petty PM, et al. Soft-tissue reconstruction of external hemipelvectomy defects. Plast Reconstr Surg 2009;124:144–155. 13. Paz IB, Wagman LD, Terz JJ, et al. Extended indications for functional limb-sparing surgery in extremity sarcoma using complex reconstruction. Arch Surg 1992;127:1278–1281. 14. Knox K, Bitzos I, Granick M, et al. Immediate reconstruction of oncologic hemipelvectomy defects. Ann Plast Surg 2006;57:184–189. 15. Ross DA, Lohman RF, Kroll SS, et al. Soft tissue reconstruction following hemipelvectomy. Am J Surg 1998;176:25–29. 16. van Garderen JA, Wiggers T, van Geel AN. Complications of the pedicled omentoplasty. Neth J Surg 1991;43:171–174. 17. Enneking W, Dunham W, Gebhardt M, Malawar M, Pritchard D. A system for the classification of skeletal resections. Chir Organi Mov 1990;75(Suppl):217–240. 18. Uchida A, Myoui A, Araki N, et al. Prosthetic reconstruction for periacetabular malignant tumors. Clin Orthop Relat Res 1996;326:238–245. 19. Kawai A, Healey JH, Boland PJ, et al. Prognostic factors for patients with sarcomas of the pelvic bones. Cancer 1998;82:851–859. 20. Glatt BS, Disa JJ, Mehrara BJ, et al. Reconstruction of extensive partial or total sacrectomy defects with a transabdominal vertical rectus abdominis myocutaneous flap. Ann Plast Surg 2006;56:526–530. 21. Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg 2004;52:22–26. 22. Miles WK, Chang DW, Kroll SS, et al. Reconstruction of large sacral defects following total sacrectomy. Plast Reconstr Surg 2000;105:2387–2394. 23. Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 2005;12:104–110.