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Femur–fibula–fillet of leg chimeric free flap for sacral-pelvic reconstruction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 1784e1787
CASE REPORT
Femurefibulaefillet of leg chimeric free flap for sacral-pelvic reconstruction Aisha J. McKnight a, Valerae O. Lewis b, Laurence D. Rhines c, Matthew M. Hanasono a,* a
Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA Department of Orthopedic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA c Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA b
Received 17 April 2013; accepted 7 May 2013
KEYWORDS Femur free flap; Fibula free flap; Fillet of leg free flap; External hemipelvectomy; Sacrectomy; Pelvic reconstruction; Sarcoma
Summary We describe the first case of a femur free flap in which we utilized the femur to restore pelvic ring continuity following a combined external hemipelvectomy-sacrectomy for cancer. We feel that the femur flap can be an important reconstructive tool for loadbearing bony reconstruction of the pelvis and spine when lower extremity amputation is required. We also utilized a fibula flap to stabilize the spine and a fillet of leg flap to provide soft tissue coverage as part of a chimeric femurefibulaefillet of leg free flap from the same limb, allowing us to reconstruct a large, complex defect with “spare parts” from the discarded lower extremity, thereby totally eliminating any donor site morbidity. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Large composite defects resulting from wide resection of extensive pelvic tumors may present the reconstructive
* Corresponding author. Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, TX 77030, USA. Tel.: þ1 713 794 1247; fax: þ1 713 794 5492. E-mail address: [email protected] (M.M. Hanasono).
surgeon with the dual challenges of restoring stability to the pelvis and spine, while also providing adequate soft tissue for wound closure. The resection may also involve ligation of the common iliac vessels, which can compromise reliability of the surrounding tissues and prevent the use of pedicled flaps altogether for reconstruction. Such challenging defects often require innovative techniques for reconstruction. We present the first case of a femur free flap, which was harvested in continuity with a fibula flap and fillet of leg flap to reconstruct a combined external hemipelvectomy-sacrectomy defect.
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.05.025
Femur-fibula-fillet of leg chimeric free flap
Case report A 22-year-old female with a recurrent high-grade osteosarcoma of the left iliac bone, with an epidural component extending into the left S1, S2, and S3 neural foramina, and tumor thrombus within the left common iliac vein. She had received preoperative chemotherapy and radiation. The approach to resection of her tumor required a staged operation over the course of two days. Stage I involved laminectomy of the L5 to S4 vertebrae, ligation of the left S1 to S4 nerve roots, posterior segmental stabilization, and arthrodesis from the lumbar spine to the pelvis. Stage II involved left external hemipelvectomy and sacrectomy. The resection ultimately resulted in a bony left sacralpelvic defect extending from the lumbar spine at the level of L4 to the pubic symphysis, and a cutaneous defect measuring approximately 20 15 cm. We planned a femurefibulaefillet of leg (3F) chimeric free flap to reconstruct the pelvic ring, stabilize the spine, and provide soft tissue coverage of the wound, respectively. To minimize ischemia time, the fibula and filet of leg were prepared while the left leg was still vascularized, before completion of the tumor resection. After the common iliac vessels were ligated and the hindquarter was amputated, the dissection of the 3F flap was completed on the back table. The main pedicle supplying the 3F free flap consisted of the common femoral artery and vein, with the femur supplied by both the profunda femoris and a branch of the superficial femoral artery (Figure 1). The vascular dissection was continued distally such that the blood supply to the fibula and fillet of leg flaps remained in continuity
Figure 1 Dissection of the left femur, fibula, and fillet of leg chimeric free flap based on the common femoral artery and vein.
1785 with the main pedicle. A 22 cm-long segment of femur was rigidly fixed posteriorly, by interdigitation into the L4 vertebral body and through and through lag screw fixation, and anteriorly to the pubic symphysis, again with lag screws, to restore continuity of the pelvic ring. The fibula was fixed to the posterior lumbar vertebral bodies and spinous processes to support the spine (Figure 2). The flap arterial anastomosis was performed between the common femoral artery and common iliac artery. The stump of the common iliac vein was too short for an anastomosis, and the inferior vena cava was completely encased in scar tissue and found to be extremely friable due to radiation changes. Therefore, the right saphenous vein was transposed from the contralateral thigh across the anterior abdomen and used as a recipient vein for the common femoral vein (Figure 3). The fillet of leg flap was then used to close the cutaneous defect (Figure 4). The patient’s postoperative course was uneventful. At 12-months following surgery, the patient is without evidence of recurrent disease and is able to ambulate with a prosthesis. Computed tomography reveals bony union of the femur and fibula to the pelvis and spine, respectively.
Discussion The femur is the longest and strongest bone in the body. Because its essential role in providing structural support to
Figure 2 Insetting of the femurefibulaefillet of leg chimeric free flap. The femur was rigidly fixed to the pubic symphysis and lumbar vertebrae, restoring pelvic ring continuity. The fibula was used to stabilize the lumbar spine, alongside titanium hardware, and the fillet of leg flap was prepared for use as part of the soft tissue closure of the wound.
1786
Figure 3 Blood supply to the femurefibulaefillet of leg chimeric free flap. The common femoral artery (flap artery, F) was anastomosed to the left common iliac artery (recipient artery, R). The common femoral vein (flap vein F), was anastomosed to the right saphenous vein (recipient vein, R), which was transposed from the contralateral leg. The popliteal artery and vein (flap artery and vein, F) supply the fillet of leg flap and the peroneal artery and vein supply the fibula flap (flap artery and vein, F).
lower extremity, use of the femur as a pedicled or free flap for osseous reconstruction in most instances. Its use as a reconstructive flap, however, should be considered following external hemipelvectomy where there is a large sacral-pelvic discontinuity. Such cases require bony reconstruction that can provide considerable strength for the load that is transferred from the spine to the pelvis in both the sitting and standing positions. Although the fibula free flap has been described for pelvic ring reconstruction following Type I internal hemipelvectomy,1 it does not have provide sufficient strength or bone stock for load bearing in the situation we encountered. Yamamoto et al.2 first described the use of a pedicled vascularized femur flap for restoration of the pelvic ring. The same group performed a cadaver study of the vascularized femur flap a year prior to its clinical application.3 This study found that the vascular supply to the femur was a nutrient vessel from the profunda femoris artery that enters the mid-shaft of the femur along the linea aspera. The nutrient vessel to the femur has also been reported as coming from the superficial femoral artery by Campbell and Chang,4 who utilized a fillet of thigh flap in combination with a pedicled femur flap for reconstruction following external hemipelvectomy and partial sacrectomy. We chose to preserve both the profunda femoris and superficial
A.J. McKnight et al.
Figure 4 Completed reconstruction, showing the left external hemipelvectomy wound closed with the fillet of leg free flap. The right thigh with the donor site incision for the saphenous vein is partially visible.
femoral blood supply to femur and felt that the additional dissection did not substantially increase the length or difficulty of surgery. In the case we present, it was necessary to perform reconstruction with the femur as a free flap, due to vascular invasion of the iliac vessels by the tumor. Free flaps are also needed in situations where a pedicled flap has inadequate reach and arc of rotation, as may have been the case in our patient, who had long defect from the pubic symphysis to the L4 vertebral body. Utilizing the femur, fibula, and fillet of leg flaps from the amputated extremity, which would otherwise have been discarded, drastically reduced the morbidity of this procedure since no flap donor sites were needed from the rest of the patient’s body to reconstruct her massive and complicated wound.5 Finally, use of the saphenous vein transposed from the contralateral leg as a recipient vein has not previously been described to our knowledge, but proved to be a worthy “lifeboat” in the absence of other more local options for venous drainage of our very large chimeric free flap.
Conflicts of interest statement The authors (Aisha J. McKnight, M.D., Valerae O. Lewis, M.D., Laurence D. Rhines, M.D., Matthew M. Hanasono, M.D.) have no conflicts of interest or financial relationships to disclose.
Femur-fibula-fillet of leg chimeric free flap
Funding No funding was received for this study.
References 1. Chang DW, Fortin AJ, Oates SD, Lewis VO. Reconstruction of the pelvic ring with vascularized double-strut fibular flap following internal hemipelvectomy. Plas Reconstr Surg 2008; 121(6):1993e2000.
1787 2. Yamamoto Y, Takeda N, Sugihara T. Pelvic reconstruction with a vascular bone flap of femur. Plas Reconstr Surg 1997;100(2): 415e7. 3. Yamamoto Y, Ohura T, Sugihara T. An anatomic study for a vascularized boned flap of femur. Plas Reconstr Surg 1995;95: 520. 4. Campbell CA, Chang DW. Vascularized femur flap for stabilization after combined total sacrectomy and external hemipelvectomy. Plas Reconstr Surg 2012;129(5):888ee9e. 5. Ver Halen JP, Yu P, Skoracki RJ, Chang DW. Reconstruction of massive oncologic defects using free fillet flaps. Plas Reconstr Surg 2010;125(3):913e22.
CASE REPORT
Femurefibulaefillet of leg chimeric free flap for sacral-pelvic reconstruction Aisha J. McKnight a, Valerae O. Lewis b, Laurence D. Rhines c, Matthew M. Hanasono a,* a
Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA Department of Orthopedic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA c Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA b
Received 17 April 2013; accepted 7 May 2013
KEYWORDS Femur free flap; Fibula free flap; Fillet of leg free flap; External hemipelvectomy; Sacrectomy; Pelvic reconstruction; Sarcoma
Summary We describe the first case of a femur free flap in which we utilized the femur to restore pelvic ring continuity following a combined external hemipelvectomy-sacrectomy for cancer. We feel that the femur flap can be an important reconstructive tool for loadbearing bony reconstruction of the pelvis and spine when lower extremity amputation is required. We also utilized a fibula flap to stabilize the spine and a fillet of leg flap to provide soft tissue coverage as part of a chimeric femurefibulaefillet of leg free flap from the same limb, allowing us to reconstruct a large, complex defect with “spare parts” from the discarded lower extremity, thereby totally eliminating any donor site morbidity. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Large composite defects resulting from wide resection of extensive pelvic tumors may present the reconstructive
* Corresponding author. Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, TX 77030, USA. Tel.: þ1 713 794 1247; fax: þ1 713 794 5492. E-mail address: [email protected] (M.M. Hanasono).
surgeon with the dual challenges of restoring stability to the pelvis and spine, while also providing adequate soft tissue for wound closure. The resection may also involve ligation of the common iliac vessels, which can compromise reliability of the surrounding tissues and prevent the use of pedicled flaps altogether for reconstruction. Such challenging defects often require innovative techniques for reconstruction. We present the first case of a femur free flap, which was harvested in continuity with a fibula flap and fillet of leg flap to reconstruct a combined external hemipelvectomy-sacrectomy defect.
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.05.025
Femur-fibula-fillet of leg chimeric free flap
Case report A 22-year-old female with a recurrent high-grade osteosarcoma of the left iliac bone, with an epidural component extending into the left S1, S2, and S3 neural foramina, and tumor thrombus within the left common iliac vein. She had received preoperative chemotherapy and radiation. The approach to resection of her tumor required a staged operation over the course of two days. Stage I involved laminectomy of the L5 to S4 vertebrae, ligation of the left S1 to S4 nerve roots, posterior segmental stabilization, and arthrodesis from the lumbar spine to the pelvis. Stage II involved left external hemipelvectomy and sacrectomy. The resection ultimately resulted in a bony left sacralpelvic defect extending from the lumbar spine at the level of L4 to the pubic symphysis, and a cutaneous defect measuring approximately 20 15 cm. We planned a femurefibulaefillet of leg (3F) chimeric free flap to reconstruct the pelvic ring, stabilize the spine, and provide soft tissue coverage of the wound, respectively. To minimize ischemia time, the fibula and filet of leg were prepared while the left leg was still vascularized, before completion of the tumor resection. After the common iliac vessels were ligated and the hindquarter was amputated, the dissection of the 3F flap was completed on the back table. The main pedicle supplying the 3F free flap consisted of the common femoral artery and vein, with the femur supplied by both the profunda femoris and a branch of the superficial femoral artery (Figure 1). The vascular dissection was continued distally such that the blood supply to the fibula and fillet of leg flaps remained in continuity
Figure 1 Dissection of the left femur, fibula, and fillet of leg chimeric free flap based on the common femoral artery and vein.
1785 with the main pedicle. A 22 cm-long segment of femur was rigidly fixed posteriorly, by interdigitation into the L4 vertebral body and through and through lag screw fixation, and anteriorly to the pubic symphysis, again with lag screws, to restore continuity of the pelvic ring. The fibula was fixed to the posterior lumbar vertebral bodies and spinous processes to support the spine (Figure 2). The flap arterial anastomosis was performed between the common femoral artery and common iliac artery. The stump of the common iliac vein was too short for an anastomosis, and the inferior vena cava was completely encased in scar tissue and found to be extremely friable due to radiation changes. Therefore, the right saphenous vein was transposed from the contralateral thigh across the anterior abdomen and used as a recipient vein for the common femoral vein (Figure 3). The fillet of leg flap was then used to close the cutaneous defect (Figure 4). The patient’s postoperative course was uneventful. At 12-months following surgery, the patient is without evidence of recurrent disease and is able to ambulate with a prosthesis. Computed tomography reveals bony union of the femur and fibula to the pelvis and spine, respectively.
Discussion The femur is the longest and strongest bone in the body. Because its essential role in providing structural support to
Figure 2 Insetting of the femurefibulaefillet of leg chimeric free flap. The femur was rigidly fixed to the pubic symphysis and lumbar vertebrae, restoring pelvic ring continuity. The fibula was used to stabilize the lumbar spine, alongside titanium hardware, and the fillet of leg flap was prepared for use as part of the soft tissue closure of the wound.
1786
Figure 3 Blood supply to the femurefibulaefillet of leg chimeric free flap. The common femoral artery (flap artery, F) was anastomosed to the left common iliac artery (recipient artery, R). The common femoral vein (flap vein F), was anastomosed to the right saphenous vein (recipient vein, R), which was transposed from the contralateral leg. The popliteal artery and vein (flap artery and vein, F) supply the fillet of leg flap and the peroneal artery and vein supply the fibula flap (flap artery and vein, F).
lower extremity, use of the femur as a pedicled or free flap for osseous reconstruction in most instances. Its use as a reconstructive flap, however, should be considered following external hemipelvectomy where there is a large sacral-pelvic discontinuity. Such cases require bony reconstruction that can provide considerable strength for the load that is transferred from the spine to the pelvis in both the sitting and standing positions. Although the fibula free flap has been described for pelvic ring reconstruction following Type I internal hemipelvectomy,1 it does not have provide sufficient strength or bone stock for load bearing in the situation we encountered. Yamamoto et al.2 first described the use of a pedicled vascularized femur flap for restoration of the pelvic ring. The same group performed a cadaver study of the vascularized femur flap a year prior to its clinical application.3 This study found that the vascular supply to the femur was a nutrient vessel from the profunda femoris artery that enters the mid-shaft of the femur along the linea aspera. The nutrient vessel to the femur has also been reported as coming from the superficial femoral artery by Campbell and Chang,4 who utilized a fillet of thigh flap in combination with a pedicled femur flap for reconstruction following external hemipelvectomy and partial sacrectomy. We chose to preserve both the profunda femoris and superficial
A.J. McKnight et al.
Figure 4 Completed reconstruction, showing the left external hemipelvectomy wound closed with the fillet of leg free flap. The right thigh with the donor site incision for the saphenous vein is partially visible.
femoral blood supply to femur and felt that the additional dissection did not substantially increase the length or difficulty of surgery. In the case we present, it was necessary to perform reconstruction with the femur as a free flap, due to vascular invasion of the iliac vessels by the tumor. Free flaps are also needed in situations where a pedicled flap has inadequate reach and arc of rotation, as may have been the case in our patient, who had long defect from the pubic symphysis to the L4 vertebral body. Utilizing the femur, fibula, and fillet of leg flaps from the amputated extremity, which would otherwise have been discarded, drastically reduced the morbidity of this procedure since no flap donor sites were needed from the rest of the patient’s body to reconstruct her massive and complicated wound.5 Finally, use of the saphenous vein transposed from the contralateral leg as a recipient vein has not previously been described to our knowledge, but proved to be a worthy “lifeboat” in the absence of other more local options for venous drainage of our very large chimeric free flap.
Conflicts of interest statement The authors (Aisha J. McKnight, M.D., Valerae O. Lewis, M.D., Laurence D. Rhines, M.D., Matthew M. Hanasono, M.D.) have no conflicts of interest or financial relationships to disclose.
Femur-fibula-fillet of leg chimeric free flap
Funding No funding was received for this study.
References 1. Chang DW, Fortin AJ, Oates SD, Lewis VO. Reconstruction of the pelvic ring with vascularized double-strut fibular flap following internal hemipelvectomy. Plas Reconstr Surg 2008; 121(6):1993e2000.
1787 2. Yamamoto Y, Takeda N, Sugihara T. Pelvic reconstruction with a vascular bone flap of femur. Plas Reconstr Surg 1997;100(2): 415e7. 3. Yamamoto Y, Ohura T, Sugihara T. An anatomic study for a vascularized boned flap of femur. Plas Reconstr Surg 1995;95: 520. 4. Campbell CA, Chang DW. Vascularized femur flap for stabilization after combined total sacrectomy and external hemipelvectomy. Plas Reconstr Surg 2012;129(5):888ee9e. 5. Ver Halen JP, Yu P, Skoracki RJ, Chang DW. Reconstruction of massive oncologic defects using free fillet flaps. Plas Reconstr Surg 2010;125(3):913e22.