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The surgical technique for temporarily occluding the common iliac artery during hemipelvectomy has been described. Not only can this technique significantly reduce the blood loss and operative time, but it may also minimize postoperative complications and increase the chances of a complete eradication of the primary malignant disease.
Five patients underwent hemipelvectomy and reconstruction for the treatment of a primary malignant tumor involving the acetabulum. There were no intraoperative complications and only one postoperative complication. All patients were ambulating within one week of surgery. During the follow up period which averaged 4 years, all patients remained ambulatory and pain-free, and none showed radiographic evidence of loosening or subsidence of the prosthesis or pins.
Two patients, one with and one without a history of nephrectomy for renal cell carcinoma, presented with lower abdominal pain. One of them, a 49-year-old man, had tumors in the right kidney and the right ischiadic bone. He underwent nephrectomy and pathologic findings showed renal cell carcinoma (tubular type, granular cell subtype, INF-gamma, G2). The other patient, a 33-year-old man with a previous history of left nephrectomy for renal cell carcinoma (tubular type, granular cell subtype, INF-alpha, G2), was found to have a large tumor in the pelvis, extending from the pubic and iliac bones to the hip joint. Both patients underwent embolization of the hypervascular mass using a vascular coil followed by hemipelvectomy under general anesthesia. The pathology reports confirmed bone metastases from renal cell carcinoma. Both patients survived surgery and their postoperative courses were uneventful without urinary or bowel incontinence. However, impaired potency was noted in the latter case. Immunotherapy with INF-alpha was resumed immediately after surgery.
Various surgical methods have been used for reconstruction after limb salvage surgery for pelvic tumours. We present a case of use of the Ilizarov technique as a second stage adjunct, for the improvement of function, after first stage tumour resection and arthrodesis. This technique is suitable for selected patients with tumour-free survival following the initial resection. Though not described before, our experience indicates it is an alternative to a mammoth one stage internal hemipelvectomy with reconstruction, that is often attempted even though there is a high risk of local recurrence and distant metastasis.
A case- review describing a desmoid in a young female. The tumor originated at the tendinuous attachment of the m. rectus abdominis on the pubic bone, which had had two relapses. During the third--so far the latest--procedure it required left-sided hemipelvectomy with resection of the rectum and a part of the vagina. The patient was instructed about the serious character of the disease, the requirement for the radical resection and about the requirement for a careful long-term follow-up of the patient after the procedure.
The authors report the results of 76 hemipelvectomies performed from 1978 to 1988 in malignant neoplasms of the hip region. Several surgical techniques were employed, including King and Steelquist's "classic" technique (77%), the technique involving the anterior flap of the thigh (9%), and the technique involving the subcutaneous gluteal flap (14%). In 8 cases palliative surgery was performed. Of the remaining 68 patients, 31 (45%) are alive and show no signs of the disease after an average of 44 months. Postoperative complications are discussed in relation to surgical technique and previous adjuvant therapy; the subcutaneous gluteal flap technique exposes the patient to the greatest risk of major complications (54%), while the "classic" technique is the most reliable, although there was superficial infection in 18% of cases. Fifty percent of the patients previously treated with radiotherapy suffered local postoperative complications. In order to reduce local recurrence, special care is advised in the preoperative stages and in the execution of the pelvic osteotomies.
This report documents a patient with an open pelvic fracture with gross contamination and partial avulsion of soft tissues with transection of femoral artery and vein, femoral nerve, and a stretch injury to the sciatic nerve. Initially, an attempt was made to treat with above-knee amputation, but due to massive soft tissue loss, this was not feasible. A left hemipelvectomy was done with closure of the wound. The patient required 14 units of blood. He was discharged and is now ambulatory with a prosthesis.
We report a case of haemorrhagic necrosis after hemipelvectomy, which shows nearly all characteritic criterions of local Sanarelli-Shwartzman-phenomenon.
Interscapulothoracic amputation, disarticulation of the hip and hemipelvectomy were performed relatively seldom in the past. The results in 38 patients demonstrate that the aim to save the extremity at all events at the beginning of treatment will often lead to incurable conditions later on. Radical surgery of sarcomas of the extremities is the only chance for cure.
Hemipelvectomy utilizing an anterior myocutaneous flap is indicated for aggressive tumors of the buttock and proximal portion of the posterior thigh. A large operative defect created posteriorly by amputation of the lower extremity, hemipelvis, and buttock is covered by a myocutaneous flap of quadriceps femoris muscle and overlying skin and subcutaneous tissue. The superficial femoral artery is preserved to sustain the myocutaneous flap.
Emergency hemipelvectomy (HP) is a rare procedure. Only three incidents have been previously reported. This paper describes six additional cases, analyzes our results, and sets forth criteria for patient selection. There were five men and one woman. The median age was 38.5 years. Primary underlying diseases were sarcoma (three cases), peripheral vascular disease (one), deep vein thrombosis (one), and drug abuse (one). Life-threatening peripelvic sepsis and hemorrhage were indications for emergency HP. All six patients had multiple procedures prior to definitive HP. Four classical and two modified HPs were performed. The mean operative time was 3.5 hours, the mean blood loss 2292 ml. There were no intraoperative complications. The median duration of hospitalization was 56 days. Five of six patients were saved. Life-threatening peripelvic sepsis or hemorrhage associated with tumor recurrence, radiation, or failed vascular reconstruction is an indication for emergency HP. Neither age nor physical condition should be a deterrent. The patient should not be allowed to advance to a premorbid state before HP is considered, although concomitant intra-abdominal disease is a contraindication. HP is recommended in lieu of hip disarticulation. We anticipate that the need for emergency HP will increase as limb salvage procedures for extremity sarcomas and dysvascular disease become more frequent.
Energy expenditure was measured using a metabolic measurement cart (MMC) for 8 patients with hip disarticulation (HD, group 1), 10 patients with hemipelvectomy (hp, group 2), and 11 able-bodied subjects (group 3). Velocity and O2 consumption of comfortable, fast, and slow walking speeds were measured with a MMC. Comfortable walking speeds with HD and hp were 51% to 61% of controls (p less than 0.001), but there was no difference in O2 uptake per minute among the three groups. Fast walking speeds for groups 1 and 2 was 70% to 75% of comfortable walking speeds in group 3 (p less than 0.01), and the mean O2 uptake of fast walking speeds in groups 1 and 2 was 40% to 50% more than that of group 3 at comfortable speeds. Energy cost per unit distance (work) was 80% to 125% greater with patient groups than with able-bodied subjects. The difference between the pre- and immediate postexercise pulse rates for comfortable walking speeds were higher in groups 1 and 2 than in group 3.
In presenting two cases of chondrosarcoma of the pelvis treated by hemipelvectomy, the writers discuss the therapeutic possibilities in dealing with this neoplasm at already far advanced stages.
Hemipelvectomy is most frequently indicated for sarcoma of the upper thigh, hip, or pelvis. With the patient in the lateral position the incision is made through the anterior abdominal wall, and the iliac vessels are dissected free and divided just distal to the aortic bifurcation. The multiple visceral branches of the internal iliac vessels are divided and ligated to expose the sacral nerve roots deep within the pelvis. The posterior skin flap is dissected free and the gluteus maximus muscle severed from its origin on the sacrum. Back muscles are detached from the wing of the ilium and the psoas muscle with accompanying obturator and femoral nerves is divided. The pelvis begins to open as the symphysis pubis is divided. Next the sacral nerve roots are divided and anterior capsule of the sacroiliac joint. The muscles and ligaments of the pelvic floor are severed including the urogenital diaphragm, levator ani muscle, sacrotuberous ligament, and sacrospinalis ligament. The specimen is released by severing the sacroiliac joint posteriorly. The operative defect is closed by suturing gluteal fascia to inguinal ligament over suction drains.
Hemangiopericytoma is a rare vascular tumor originating from pericytes. The main manifestation is a growing mass. Although computed tomodensitometry and MRI are the best diagnostic procedures, the diagnosis is made only after microscopic examination. The malignancy of this tumor is not well established. In fact, there is a continuum between benign and malignant hemangiopericytoma. The malignancy is estimated by the number of mitoses and the cellularity. Recurrences occur in 60% of cases. The best treatment is surgical excision. The role of radiation therapy and chemotherapy is not well established. The history of a 51-year-old woman treated by internal hemipelvectomy is presented here.
Unlike osteosarcoma and Ewing's sarcoma chondrosarcomas are primarily surgically managed as they are resistant to chemo- and radio-therapy. A female patient, aged 36 years, was operated in 1992 for pelvic chondroma; a year later she was reoperated due to local recurrence, and diagnosis of chondrosarcoma was established. Because of tumour regrowth she was referred to our institution for hemipelvectomy. The operative team consisted of and orthopaedic surgeon, an urologist, and a general surgeon. A (large) tumour was completely removed. The patient's recovery was rapid, and she is now able of controlling urination and defecation. This kind of operation is extensive and traumatic, but it is useful in appropriately selected cases.
The care of patients refusing blood transfusion who require major ablative surgery for malignancy is a continuing challenge. The use of recombinant human erythropoietin is clearly efficacious in patients with renal disease and may be useful in anemic patients who refuse transfusion. Herein, we report a successful extended hemipelvectomy in a Jehovah's Witness using recombinant human erythropoietin support.
The twenty-fifth reported case of survival following traumatic hemipelvectomy is presented. Our patient is the fourth female survivor and the second who escaped associated injuries to either the genito-urinary system or the rectum.