Limb salvage in traumatic hemipelvectomy: case series with surgical management and review of the literature.

BACKGROUND: Traumatic hemipelvectomies are rare and serious injuries. The surgical management was described in several case studies, with primary amputation often performed to save the patient's life. METHODS: We report of two survivors with complete traumatic hemipelvectomy resulting in ischemia and paralyzed lower extremity. Due to modern emergency medicine and reconstructive surgery, limb salvage could be attained. Long-term outcome with quality of life was assessed one year after the initial accident. RESULTS AND CONCLUSIONS: The patients were able to mobilize themselves and live an independent life. The extremities remained without function and sensation. Urinary continence and sexual function were present and the colostomy could be relocated in both patients. Both patients support limb salvage, even having difficulties and follow-up treatments. Concomitant cases are required to consolidate the findings. LEVEL OF EVIDENCE: IV.

Internal Hemipelvectomy for primary bone sarcomas using intraoperative patient specific instruments- the next step in limb salvage concept.

BACKGROUND: During pelvic Sarcoma resections, Surgeons often struggle to obtain negative margins while minimizing collateral damage and maintaining limb function. These complications are usually due to the complex anatomy of the pelvis. Here we present an accurate 3D surgical approach, including pre-operative printing of models and intraoperative patient-specific instruments (PSIs) for optimizing pelvic sarcoma resections. METHODS: This single-center retrospective study (N = 11) presents surgical, functional, and oncological outcomes of patients (average age 14.6 +/- 7.6 years, 4 males) who underwent pelvic sarcoma resections using a 3D surgical approach between 2016 and 2021. All patients were followed up for at least 24 months (mean = 38.9 +/- 30.1 months). RESULTS: Our results show promising surgical, oncological, and functional outcomes. Using a 3D approach, 90.9% had negative margins, and 63.6% did not require reconstruction surgery. The average estimated blood loss was 895.45 ± 540.12 cc, and the average surgery time was 3:38 ± 0.05 hours. Our results revealed no long-term complications. Three patients suffered from short-term complications of superficial wound infections. At 24 month follow up 72.7% of patients displayed no evidence of disease. The average Musculoskeletal Tumor Society (MSTS) score at 12 months was 22.81. CONCLUSION: 3D technology enables improved accuracy in tumor resections, allowing for less invasive procedures and tailored reconstruction surgeries, potentially leading to better outcomes in function and morbidity. We believe that this approach will enhance treatments and ease prognosis for patients diagnosed with pelvic sarcoma and will become the standard of care in the future.

Tratamiento multidisciplinario de condrosarcoma gigante de fémur proximal mediante hemipelvectomía externa y reconstrucción con colgajo pediculado tipo fillet flap: presentación de un caso clínico / Multidisciplinary treatment of giant chondrosarcoma of the proximal femur by external hemipelvectomy and reconstruction with a pedunculated fillet flap: presentation of a clinical case / Tratamento multidisciplinar do condrossarcoma gigante do fêmur proximal por hemipelvectomia externa e reconstrução com retalho fillet flap: apresentação de um caso clínico

El condrosarcoma forma parte de los tumores primarios malignos más frecuentes. Las localizaciones pélvicas y de raíz de muslo requerirán abordajes amplios con la consecuente dificultad de cobertura de partes blandas. La hemipelvectomía externa es habitualmente el procedimiento de elección para estas localizaciones. Implica la resección de la extremidad inferior en bloque asociada a la hemipelvis ipsilateral, dando como resultado un gran defecto de cobertura. En algunas circunstancias, la extensa resección de partes blandas hace imposible la utilización de colgajos rotacionales locales. La reconstrucción con colgajo tipo "Fillet flaps" ofrece a estos defectos de partes blandas la opción de lograr una adecuada cobertura. El objetivo del trabajo es mostrar la resolución de un caso poco convencional de condrosarcoma de fémur proximal y su reconstrucción de partes blandas con un método nunca antes utilizado en nuestro medio.

Chondrosarcoma is one of the most frequent malignant primary tumors. Pelvic and proximal femur locations require extensive approaches with the consequent difficulty of soft tissue reconstruction. External hemipelvectomy is usually the procedure for these locations. It involves total en bloc resection of the lower extremity associated with ipsilateral hemipelvis, resulting in a large coverage defect. In some cases, local rotational flaps are impossible. Reconstruction with fillet flaps offers an adequate coverage for soft tissue defects. The objective of this study is to show the resolution of an unconventional case of chondrosarcoma of the proximal femur and its soft tissue reconstruction with a method never before used in our country.

O condrossarcoma é um dos tumores primários malignos mais frequentes. As localizações das raízes pélvicas e da coxa exigirão amplas abordagens com a conseqüente dificuldade em cobrir os tecidos moles. A hemipelvectomia externa costuma ser o procedimento de escolha para esses locais. Envolve a ressecção do membro inferior em bloco associado à hemipelve ipsilateral, resultando em um grande defeito de cobertura. Em algumas circunstâncias, a ressecção extensa de partes moles impossibilita o uso de retalhos rotacionais locais. A reconstrução com retalhos de filé oferece a esses defeitos de tecidos moles a opção de obter uma cobertura adequada. O objetivo deste trabalho é mostrar a resolução de um caso não convencional de condrossarcoma do fêmur proximal e sua reconstrução de partes moles com método nunca antes utilizado em nosso meio.

Evaluation of a novel classification system to predict local recurrence in sarcoma patients undergoing hemipelvectomy with iliosacral resection.

AIMS: Iliosacral sarcoma resections have been shown to have high rates of local recurrence (LR) and poor overall survival. There is also no universal classification for the resection of pelvic sarcomas invading the sacrum. This study proposes a novel classification system and analyzes the survival and risk of recurrence, when using this system. METHODS: This is a retrospective analysis of 151 patients (with median follow-up in survivors of 44 months (interquartile range 12 to 77)) who underwent hemipelvectomy with iliosacral resection at a single centre between 2007 and 2019. The proposed classification differentiates the extent of iliosacral resection and defines types S1 to S6 (S1 resection medial and parallel to the sacroiliac joint, S2 resection through the ipsilateral sacral lateral mass to the neuroforamina, S3 resection through the ipsilateral neuroforamina, S4 resection through ipsilateral the spinal canal, and S5 and S6 contralateral sacral resections). Descriptive statistics and the chi-squared test were used for categorical variables, and the Kaplan-Meier survival analysis were performed. RESULTS: Resections were S1 in 25/151 patients (17%), S2 in 70/151 (46%), S3 in 33/151 (22%), S4 in 77/151 (11%), S5 in 4/151 (3%), and S6 in 2/151 (1%). An internal hemipelvectomy was performed in 113/151 patients (75%), and 38/151 patients (25%) had an external hemipelvectomy. The predominant types of sarcoma were high-grade osteosarcoma in 48/151 patients (32%), chondrosarcoma in 41/151 (27%), Ewing sarcoma in 33/151 (22%), pleomorphic sarcoma in 17/151 (11%), and others in 2/151 (8%). LR was found in 24/151 patients (15%) with S3, S5, with S6 resections showing the highest rate of LR (p = 0.038). Overall, 19/151 patients (16%) had evidence of metastastic disease at the time of surgery and these patients showed poorer survival when compared to patients with no metastasis. CONCLUSION: The proposed classification can help to report and compare different surgical and reconstructive approaches in these difficult cases who are still have a considerable risk of LR. Cite this article: Bone Joint J 2022;104-B(2):290-296.

Pelvic ring reconstruction with double-barreled fibular free flap: A systematic review.

INTRODUCTION: Pelvic ring reconstruction after internal hemipelvectomy is an extremely challenging surgical procedure, and mandatory reconstruction is to provide a durable and pain-free functional outcome, especially for young, active patients. One of the most widely employed techniques is reconstruction with a double-barreled fibular free flap (DBF). The aim of our work was an in-depth analysis of the outcome of pelvic ring reconstruction performed using the above-mentioned method, in particular looking for a correlation between the fixation technique and either ambulation status or complications. MATERIALS AND METHODS: A systematic review was performed in November 2020 using PubMed and MedLine Ovid databases according to the PRISMA guidelines and the results were statistically analyzed. RESULTS: Studies were published between 1994 and 2015. A DBF was used in each case, with a total of 30 patients. Reconstruction was performed with screws in 13 cases, Cotrel-Dubousset rod fixation in 6, screws and plate in 5, screws with external fixation in 4, and ISOLA in 2. Follow-up time ranged from 3 to 131 months. Functional outcome was excellent in 4 patients and good in 26 patients. Statistical analysis showed no statistical evidence of existing correlation between fixation technique and complications (p = .873), while statistical correlation between age and fixation technique was found (p < .001). CONCLUSION: Reconstruction of pelvic ring with DBF provides an overall good functional outcome. Our data indicate that there is no statistical evidence of existing correlation between the fixation technique and either complications or ambulation status.

Type lll internal hemipelvectomy for primary bone tumours with and without allograft reconstruction : a comparison of outcomes.

AIM: There is insufficient evidence to support bony reconstruction of the pubis after a type III internal hemipelvectomy (resection of all or part of the pubis). In this study, we compared surgical complications, postoperative pain, and functional outcome in a series of patients who had undergone a type III internal hemipelvectomy with or without bony reconstruction. METHODS: In a retrospective cohort study, 32 patients who had undergone a type III hemipelvectomy with or without allograft reconstruction (n = 15 and n = 17, respectively) were reviewed. The mean follow-up was 6.7 years (SD 3.8) for patients in the reconstruction group and 6.1 years (SD 4.0) for patients in the non-reconstruction group. Functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) scoring system and the level of postoperative pain with a visual analogue scale (VAS). RESULTS: The mean MSTS score of the patients was significantly better in patients after reconstruction (26 (SD 1.7) vs 22.7 (SD 2.0); p < 0.001). The mean visual analogue scale score for pain was significantly less in the reconstruction group (2.1 (SD 2) vs 4.2 (SD 2.2); p = 0.016). One infection occurred in each group. Bladder herniation occurred in three patients (17.6%) in the non-reconstruction group but none in the reconstruction group. Five patients (29.4%) in the non-reconstruction group and one (7%) in the reconstruction group had a limp. Graft displacement occurred in two patients in the reconstruction group. CONCLUSION: We recommend reconstruction of the bony defect after a type III hemipelvectomy: it gives a better functional result, less postoperative pain, and fewer late surgical complications. Cite this article: Bone Joint J 2021;103-B(6):1155-1159.

Soft tissue reconstruction after pelvic amputation: The efficacy and reliability of free fillet flap reconstruction.

BACKGROUND: The majority of hindquarter amputation defects can be reconstructed with local anterior or posterior thigh flaps. Less than 5% of soft tissue defects require free flap reconstruction after tumour resection. Lower extremity fillet flap is described for reconstructing such defects, but the majority of publications are case reports or short single institutional series. There is a lack of data regarding the oncological outcomes of this highly selected patient group. METHODS: Three tertiary sarcoma units treated twelve patients with hindquarter amputation or hip disarticulation for oncological indications with a free flap reconstruction of the soft tissue defect. RESULTS: The median age of patients was 60 (range 12-76) years. Bone resection was carried out through the SI-joint in six patients and through the sacrum in five patients, with one patient undergoing hip disarticulation. Nine patients had R0 resection margin and three had R1 resection. The median surgical time and flap ischaemia time was 420 (249-650) and 89 (64-210) min, respectively. Median hospital and ICU stay was 18 (10-42) and 3 (1-8) days, respectively. Median blood loss was 2400 (950-10000) ml. There were three returns to theatre due to vascular compromise, with one total flap loss due to arterial thrombosis. Overall survival was 58% (95%CI 28-91%) both at 1-year and at 3-years. DISCUSSION: Carefully selected patients requiring hindquarter amputation with extensive soft tissue defect necessitating free flap reconstruction can be reconstructed with a lower extremity free fillet flap with low rate of local wound complications. Survival of these patients is similar to that in patients requiring less extensive resection.

Pelvic Ewing sarcoma: a retrospective outcome analysis of 104 patients who underwent pelvic tumor resection at a single supra-regional center.

BACKGROUND: Local treatment in pelvic Ewing sarcoma (ES) consists of operation, radiation therapy, or a combination of both. Reported outcomes vary depending on the treatment modality performed. It is the objective of this study to analyze surgical outcome and complications as well as oncological outcome and complications of chemo- and radiation therapy in this patient cohort and evaluate prognostic factors. METHODS: Retrospective review of 104 patients who underwent tumor resection for pelvic ES from 1988 to 2014. RESULTS: All patients underwent pelvic resection and radiation therapy was administered in 77.9%. Margins were clear in 94.2%. The response to chemotherapy was good in 78.8%. Local recurrence occurred in 7.7%. The presence of distant metastases at the time of operation was the most important negative predictor for overall survival (p = 0.003). The cumulative 5- and 10-year survival rates were 82.7% and 80.1% for non-metastasized and 61.4% and 41.6% for metastasized pelvic ES at operation. In the presence of a single-distant metastatic site at operation compared to multiple metastatic sites, the cumulative survival rates were 64.3% versus 50% at five and 50.7% versus 16.7% at 10 years. CONCLUSIONS: A combined treatment approach of tumor resection and radiation therapy leads to a local control and overall survival rates comparable with those of extremity locations in this study's patient cohort with localized pelvic ES. Therefore, surgical tumor resection (combined with (neo-)adjuvant radiation therapy) in non-metastatic pelvic ES seems feasible. In metastatic patients, however, the significance of tumor resection as a part of local treatment remains less certain and improved outcomes of combined local treatment approaches need to be weighed against these patients' prognosis and quality of life.

Targeted muscle reinnervation following external hemipelvectomy or hip disarticulation: An anatomic description of technique and clinical case correlates.

BACKGROUND: Targeted muscle reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates. METHODS: Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations. RESULTS: A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft. CONCLUSIONS: This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.

Pelvic ring reconstruction with segmental spinal instrumentation after complete type I pelvic resection.

BACKGROUND AND OBJECTIVES: Internal hemipelvectomy is a complex procedure used to treat malignancy that involves the pelvis. Reconstruction of the pelvis after type I or type I/IV resection remains controversial due to high complication rates and debatable functional benefit. Modern reconstruction options may provide a rapid, intuitive, and reliable way to reconstitute the pelvic ring. METHODS: This is a retrospective case series of four patients who underwent a novel reconstruction method involving computer navigation and segmental spinal instrumentation applied to the pelvis after type I or type I/IV pelvic resection for malignancy between 2015 and 2020. RESULTS: Time to ambulation postoperatively ranged from 1 to 7 days, and median length of hospital stay was 8.5 (7.5, 10.5) days. Complications included wound necrosis in two patients that did not require reoperation and wound infection in one patient that required irrigation and debridement. There was no radiographic evidence of hardware loosening or failure on follow-up. Three patients remain alive and two remain disease-free. At most recent follow-up, all patients were able to ambulate and perform activities of daily living. CONCLUSIONS: The technique for pelvic reconstruction described allows for rapid fixation intraoperatively with few complications and satisfactory functional results in this limited series.

Restoration of Spinopelvic Continuity with the Free Fibula Flap after Limb-Sparing Oncologic Resection Is Associated with a High Union Rate and Superior Functional Outcomes.

BACKGROUND: Type 1 internal hemipelvectomies and total sacrectomies cause significant biomechanical instability, demanding pelvic ring reconstruction for ambulation and torso support. Previously described methods include autografts, allografts, and implants, commonly with poor long-term outcomes. The authors hypothesized that the free fibula flap for spinopelvic reconstruction is safe and effective, and associated with a high bony union rate and superior functional outcomes. METHODS: The authors performed a retrospective review of all patients who underwent free fibula flap surgery after internal hemipelvectomy or total sacrectomy at M. D. Anderson Cancer Center from 2003 to 2018. The primary outcome was radiographic evidence of bony union. Secondary outcomes included surgical-site occurrence and lower extremity function. Univariate and multivariate logistic regression analyses were performed. RESULTS: Forty-seven patients were included (internal hemipelvectomy, n = 38; total sacrectomy, n = 9). The mean follow-up was 3.3 years and the most common abnormality was chondrosarcoma (30.4 percent). The nonunion rate was 9.7 percent and the surgical-site occurrence rate was 34 percent; there were no flap losses. Greater age was significantly associated with nonunion (OR, 1.1; 95 percent CI, 1 to 1.2; p = 0.003), whereas obesity was the only independent predictor of surgical-site occurrence (OR, 9.2; 95 percent CI, 1.2 to 71.3; p = 0.03). Functional metrics approached those of adult norms by 3 years postoperatively. Compared to internal hemipelvectomy patients, patients undergoing total sacrectomy had more comorbidities, a higher complication rate, and a worse functional outcome. CONCLUSION: The free fibula flap for spinopelvic reconstruction is safe and effective, and is associated with a high bony union rate and superior functional outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Internal Hemipelvectomy and Reconstruction Assisted by 3D Printing Technology Using Premade Intraoperative Cutting and Placement Guides in a Patient With Pelvic Sarcoma: A Case Report.

CASE: We describe the case of a 75-year-old patient diagnosed with high-grade epithelioid hemangioendothelioma in the left hemipelvis. She underwent an internal hemipelvectomy, followed by reconstruction with a tumor prosthesis with iliac anchorage using 3D-printed cutting and placement guides. Eighteen months postoperatively, she is pain-free and walks without appliances. CONCLUSIONS: Using 3D-printed guides could be an appropriate alternative for patients with aggressive bone tumors in the pelvic area that require hemipelvectomy and reconstruction using a prosthesis with iliac anchorage. 3D-printed cutting guides allow precise resection with appropriate margins, could reduce the risk of injuring critical structures, and facilitate proper prosthetic component positioning.

Unusual localization and aggressive progression of large infantile fibrosarcoma.

Infantile fibrosarcoma is a very rare soft tissue tumor in infants and children most commonly located in extremities. It constitutes less then 1 percent of all childhood cancers. Prognosis and clinical course of it is relatively good compared to adult forms. Local recurrence is common but metastasis is infrequent. In this case report we present infantile fibrosarcoma with relapse and lung metastasis despite neoadjuvant chemotherapy, pelvic reconstruction surgery with wide surgical excision and adjuvant chemotherapy protocol. The patient was a 2-year-old girl at the time of diagnosis, and there was a huge mass in pelvic region. After neoadjuvant chemotherapy, type 1 pelvic resection and pelvic reconstruction with bone cement performed. The patient presented with relapse and lung metastasis 6 months after the surgery. This is the first report of pelvic infantile fibrosarcoma with pelvic resection surgery. This case suggests that these tumors may exhibit unpredictable clinical behavior.

Free fillet lower leg flap for coverage after hemipelvectomy or hip disarticulation.

INTRODUCTION: Tumor resection is the gold standard treatment for soft tissue and bone sarcomas. In the pelvis, this may require a hemipelvectomy that can compromise primary skin closure. Flaps are essential in this context; however the vascularization of potential pedicled flaps may have been removed during tumor excision. Using healthy tissue from the amputated limb as a free flap is an excellent coverage option. HYPOTHESIS: The free fillet flap from an amputated lower limb is a simple and reliable coverage technique after hemipelvectomy or hip disarticulation. MATERIAL AND METHODS: Seven patients were operated on at three specialty centers: six transpelvic amputations (external hemipelvectomy) and one hip disarticulation. In three cases, the flap consisted of the superficial posterior compartment of the calf area and in the three other cases, the lower leg compartments with the fibula and its intact periosteum. Complications were documented. RESULTS: Clear resection margins were achieved in all patients. The mean follow-up at the final visit was 13 months (range, 6.5 to 21 months). Six patients had complications but only one resulted in loss of the flap. Four patients were able to be fitted with a hip prosthesis. DISCUSSION: The free fillet flap from an amputated lower limb is a reliable coverage technique (86%) after hemipelvectomy or hip disarticulation. In the 16 cases previously reported in the literature, there were no wound-healing failures. Local flaps are often too fragile with insufficient muscular padding. This free flap is the preferred first-line technique as it spares other potential free flaps in case of failure without increasing the morbidity of a procedure that is already extensive. This coverage technique should be one the options considered after external hemipelvectomy. LEVEL OF EVIDENCE: IV, retrospective study.

Using a kidney pump to perfuse a free filet flap for reconstruction after hemipelvectomy: A case report.

Long ischemia times adversely affect free flap survival, and large muscle flaps are particularly vulnerable. Hypothermic machine perfusion (HMP) is a well-established method of organ preservation, and recent literature has detailed the use of HMP to extend free flap ischemia times, predominantly in the laboratory setting. One limitation in the study and adoption of free flap HMP has been the availability of standardized perfusion machinery, as thus far institutions have built their own devices. We present a case of a 75-year-old woman with dedifferentiated chondrosarcoma of her right proximal femur. She underwent a "spare parts" surgery using a filet flap from her lower leg. Due to an obligate long ischemia time between flap harvest and revascularization, a kidney transplant perfusion pump was used to flush and cool the flap. After completion of the disarticulation, free tissue transfer proceeded successfully. The patient had an uncomplicated post-operative course until developing a local recurrence at three months post-resection. We believe that the perfusion technology already created for solid organ transplant will have expanding indications in the future of free tissue transfer and limb replantation.

Free latissimus dorsi musculocutaneous flap for external hemipelvectomy reconstruction.

INTRODUCTION: External hemipelvectomy is one of the most extensive surgical procedures for locally advanced pelvic tumors. Stump coverage with the local tissues can be difficult in recurrent cases. Herein, we report our experience with immediate stump coverage using a free latissimus dorsi musculocutaneous (LDMC) flap after external hemipelvectomy for recurrent pelvic malignancies. METHODS: Six patients underwent external hemipelvectomy and immediate reconstruction using a free LDMC flap between November 2012 and June 2017. The mean age of the patients was 65 years (range: 63-69 years). The primary tumors were myxoid liposarcoma, chondrosarcoma, osteosarcoma, squamous cell carcinoma, and pleomorphic liposarcoma. A free LDMC flap was harvested from the ipsilateral back and transferred to the defect. When an intercostal nerve was found at the recipient site, the thoracodorsal nerve was coaptated with the intercostal nerve to reinnervate the muscle. RESULTS: The mean flap size was 23 × 10 cm and the range was 20 × 8-27 × 13.5 cm. The contralateral deep inferior epigastric vessels were used as recipient vessels in all patients. Thoracodorsal-intercostal nerve coaptation was performed in 2 patients. The flap survived in all patients. Three patients had complications of abscess formation. No patient developed postoperative hernia. CONCLUSION: Although it is challenging to do reconstruction after external hemipelvectomy, a free LDMC flap has several advantages, including a large coverage area, stability of circulation, ease of elevation, and preservation of the strength of the remaining abdominal wall. Technical tips for selecting anastomosis vessels are important and nerve coaptation could be effective.

Posterior "Open Book" approach for type 1 internal hemipelvectomy.

INTRODUCTION: Internal limb-sparing hemipelvectomy is currently the preferred surgical option for resection of pelvic tumours. Obtaining an acceptable functional outcome through the standard ilioinguinal or iliofemoral incisions, only compounds the already challenging dissection, resection and reconstruction of these extensive en-bloc extirpative oncologic operations. SURGICAL TECHNIQUE: We describe a novel surgical approach to the lateral pelvis that minimises injury to the gluteal muscles, spares the gluteal vessels and provides a broad yet shallow operative field conducive to microsurgery with sizeable vasculature in close proximity to facilitate any microsurgical reconstruction. Access to the ilium and sacrum for Enneking Type 1 and Type 4 resections respectively is obtained by reflecting a skin and soft tissue flap anteriorly while the gluteal muscles are reflected posteriorly and inferiorly. This technique minimises the amount of tissue reflected in any particular direction, therefore, providing a broad and shallow operative field which benefits the orthopaedic oncologic surgeon and the plastic reconstructive surgeon. CONCLUSION: The "posterior open-book" approach offers a promising alternative to the standard ilioinguinal or iliofemoral incisions for internal limb-sparing Type 1 hemipelvectomies while also optimising the exposure for subsequent reconstructive procedures.

Hemipelvectomy with laparoscopic abdominoperineal excision for epithelioid sarcoma treatment / Hemipelvectomia com amputação laparoscópica do reto para tratamento de sarcoma epitelioide

Abstract The epithelioid sarcoma (ES) is an unusual variant of the sarcoma, not reaching 1% of all soft tissue sarcomas. Initially reported in 1970, it has a more aggressive variant, which was classified as the "proximal-type" in 1997. These are aggressive tumors with high rates of distant metastasis and local relapses. Isolated radio and chemotherapy responses are poor and free-margin surgical resection is the treatment of choice.This is the case report of a 25-year-old male patient diagnosed with "proximal-type" ES in the perineal region. He underwent surgical resection in another institution and was later admitted to our institution with local recurrence with rectal and left thigh muscle invasion. Neoadjuvant radio-chemotherapy was performed, followed by laparoscopic abdominoperineal rectal resection and partial left hemipelvectomy associated with left lower-limb amputation. The patient had no postoperative complications and is currently undergoing outpatient follow-up. The anatomopathological analysis showed tumor-free margins.The "proximal-type" ES is a rare soft-tissue sarcoma subtype. High local recurrence, as well as the metastasis rates, makes its treatment a challenging task.

Resumo O sarcoma epitelióide (SE) é um subtipo incomum de sarcoma, não chegando a 1% dos sarcomas de partes moles. Foi inicialmente descrito em 1970, sendo que em 1997 uma variante mais agressiva foi classificada como "tipo proximal". São tumores agressivos, com altas taxas de metástases e recidiva local, com resposta pobre à quimioterapia e radioterapia isoladas. A ressecção cirúrgica com margens livres é o tratamento padrão.Apresentamos o caso de um paciente de 25 anos com SE tipo proximal avançado em região perineal, submetido a ressecção em outro serviço, evoluindo com recidiva local com invasão do canal anal e musculatura da coxa esquerda. Foi realizado tratamento radioquimioterápico neoadjuvante seguido de ressecção cirúrgica com amputação abdominoperineal do reto por videolaparoscopia associada a hemipelvectomia parcial esquerda incluindo o membro inferior esquerdo (MIE). O paciente apresentou boa evolução pós operatória e encontra-se em segmento ambulatorial. O anatomopatológico evidenciou margens cirúrgicas livres.O SE proximal é um tipo raro de sarcoma de partes moles, cujo tratamento curativo é desafiador, em virtude dos altos índices de recidiva local e metástases à distância.