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The fourteenth case of survival following traumatic hemipelvectomy is presented. Several features of these massive injuries are illustrated by this case report and provide an opportunity to suggest guidelines of surgical management, based on standard and new criteria.
This tenth survivor of traumatic hemipelvectomy was a young male involved in a collision between a car and his bicycle. As in previous cases, he sustained severe associated injuries to the genitourinary tract and rectum. Atypically he required secondary closure with autogenous skin taken from the severed lower limb, and in addition, he developed a compartment syndrome in the opposite leg.
This is a report of a 16-year-old survivor of a traumatic hemipelvectomy in combination with an amputation of the upper extremity on the ipsilateral side. The injury was caused when the patient fell under a railroad train. There were associated injuries of the genitourinary tract and the rectum. Factors that contributed to the patient's survival were: 1) the excellent care he received at the scene of the accident by the paramedics of the regional emergency care system; 2) a rapid transportation to the hospital by a life flight helicopter; and 3) a concentrated effort by the general surgery, plastic surgery, and urologic surgery teams in providing vigorous, sustained, and comprehensive preoperative, operative, and postoperative care.
We present a case of a right external hemipelvectomy for chondroblastic osteosarcoma originating from the right ilium and reconstruction with salvage parts; cardiopulmonary bypass preserved anterior thigh free flap. The resection required sacrifice of the right common iliac artery and vein and the entire right gluteus maximus muscle. The first stage of the procedure was a high above-knee amputation on the ipsilateral leg. The amputated extremity was placed on extracorporeal bypass utilizing the common femoral artery and vein. This technique, previously unreported, supported the successful utilization of the anterior thigh free flap for both soft tissue and abdominal wall facial reconstruction.
Internal hemipelvectomy, the removal of the innominate bone with the adjacent iliacus, glutei and obturator muscles is the procedure of choice when primary malignant tumors involving this bone can be encompassed and removed with this operation. However, it requires a considerable effort in rehabilitation and, thus, is more suitable for the younger patient motivated for limb salvage.
Traumatic hemipelvectomy is rarely observed, mostly because very few patients survive the initial trauma. We describe 2 cases of children who survived this trauma. The first was a 12 year-old boy who accidentally fell between a metro train and the platform. He had a severe open trauma of the pelvis with important hemorrhage. After a first operation to stop hemorrhage and do a cystotomy and a colostomy, ischemia of the lower limb led to an inter-ilio-abdominal amputation. Two months were necessary to heal this. A prosthesis was made 12 months after the accident, postponed by urinary problems. The boy also had a traumatic amputation of the left arm and an upper metaphyseal fracture of the humerus. The second case was that of an 8 year-old girl who suffered a complete traumatic amputation of the hemipelvis after a road accident. A secondary colostomy was performed because of a local infection. Once healing was achieved, the child was low to follow-up. In the literature, we found 36 survivors to this dreadful lesion (4 of them children). We analysed the different problems for the treatment of this trauma caused, and their short term consequences. An early evaluation of the lesions, rapid and intensive resuscitation, early decision to complete the traumatic amputation if necessary, with urinary and digestive derivation, are important elements towards eventual successful outcome of the treatment.
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The resection of primary malignancies in the pelvis is technically demanding as organs and structures are to be preserved and reconstruction of the defect as well as the postoperative function and rehabilitation are dependent on an optimal prosthesis. We present two patients with a sarcoma of the pelvis where for the first time a structured concept of technology integration led to a press-fit implantation of a hemipelvic prosthesis. This concept includes the design and production of a "custom-made" prosthesis as a hemipelvic substitute and the coating of this prosthesis with Bonit, a second-generation calcium phosphate, and gentamycin in watery solution. The tumor resection was done with computer-assisted surgery based on computed tomographies (CT) of the pelvis model done by rapid prototyping rather than on the CT of the patients' pelvis. With this procedure the presurgically simulated resection could be executed precisely with complete resection of the tumors and an accuracy which allowed an exact implantation of the prosthesis. The course was uneventful with primary healing and no sign of an infection or loosening after 6 months.
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