PELVIC WALL RECONSTRUCTION
INDICATIONS
 Usually chronic wounds caused by infected orthopaedic hardware or infected THR
 1-2% THR become infected
 non-healing chronically infected wounds usually have a draining sinus with
indurated woody surrounding tissues
 polymicrobiol cultures
Girdlestone procedure
 indicated in a severely infected or diseased hip joint where a hip prosthesis is not
feasible
 was commonly done for severe tuberculosis-induced destruction of the hip joint
 Cavity is left to fill with scar. Femur rides upward, and the patient's leg shortens.
People in this situation are able to walk very limited distances, using a walker and
a shoe lift.
 operation can be converted to a total hip replacement in many cases.
PRINCIPLES OF TREATMENT
 Liase with orthopaedic team
 Infected implant may require removal and replacement with antibiotic spacer in a
two satge reconstruction
Debridement
 Devitalised soft tissue, scar, bone and methylmethacrylate
 especially important is complete removal of the methylmethacrylate and the
infected and nonviable bone
Reconstruction
 well vascularized tissue
 fill dead space
 wound closure
OPERATIONS
RECTUS FEMORIS FLAP
Anatomy
 ASIS into the quadriceps patella tendon
 Type II
 Dominant by descending branch of lateral femoral circumflex artery
 Enters the muscle 10cm below the ASIS
Reconstruction
 Elevated through a lateral thigh incision
 Based on the lat. Femoral circumflex artery
 Sutured to the acetabulum
 Vastus lateralis and vastus medialis are then approximated
VASTUS LATERALIS FLAP
Anatomy
 Lateral surface of the greater tronchanter and the trochanteric line and inserts into
the rectus femoris tendon and the upper lateral patella
 Type I
 Blood supply by the descending branch of LFCA-enters the muscle 10-12 cm
below the origin
 Distal 1/3 by perforating braches of the superficial femoral artery and thus only the
proximally 2/3 can be reliably raised on the lat. Femoral circumflex artery
Reconstruction
 Lateral incision
 More difficult incision with firm vascular attachments to the femur
 Can be used incombination with the rectus fomoris
 Major drawback is significant weakness related to knee extension and lateral knee
instability
 May be used to cover the acetabulum after a Girdlestone procedure. Hamstrings
also can be used.
RECTUS ABDOMINUS FLAP
TENSOR FACIA LATA
FREE MUSCLE TRANSFER
 Latissimus dorsi
 Rectus abdominus
 Others
PELVIC WALL RECONSTRUCTION
INDICATIONS
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Infection
Pressure necrosis
Radiation injury
Trauma
Residual defects post tumour excision
MECHANISM OF PELVIC TRAUMA
1. lower extremity or pelvic avulsion by entanglement in machinery
2. MVA causing sacroiliac joint disruption and pubic symphysis separation
3. massive crush injuries to the groin disrupting the vessels, nerves, soft tissue, and
pelvic bones
 acute pelvic reconstruction is rare however the principles are the same as for large
defects post tumour ablation
 viable thigh musculature provides good options for soft tissue coverage
PELVIC TUMOURS
5-10% soft tissue and bone sarcomas involve the pelvis
remember primary and secondary tumours
preoperative imaging correctly establishes the extent of the resection and the
subsequent defect needed to be reconstructed
preoperative planning is essential
hemipelvicectomy was the standard, now newer limb sparing operations (eg internal
hemipelvectomy
ANATOMY (ESSENTIAL POINTS)
 pelvic brim is formed by the sacral promontory, iliopectineal line and pubic
symphysis
 The true and false pelvis are below and above this line
 Internal iliac divides into an anterior and posterior branch
1. Anterior branch divides into the inferior gluteal, obturator, internal
pudendal, umbilical, inferior vesical, middle rectal , uterine and vaginal
2. Posterior branch into the superior gluteal, iliolumbar and lateral sacral
arteries
OPERATIONS
Follow the reconstructive ladder
Usually non graftable bed with exposed bone, nerves, vessels, joints
Local muscle flaps for smaller defects:
1. Gluteus maximus
2. Rectus abdominus
3. Rectus femoris
4. Vastus lateralis
5. Tensor fascia lata
6. Gracilis
Fasciocutaneous flaps
1. Anterolateral thigh flap
2. Lateral thigh flap
3. Medial thigh flap
4. Anteromedial thigh flap
May require the use of prosthetic material
Close fascial and bony defects
for reconstruction divide the pelvis into anterior, lateral and posterior wall
defects
ANTERIOR DEFECTS
Anterior pelvic resection is usually stable
Abdominoperineal hernias are problematic without reconstruction
Fascia needs to be incorporated in the recon to prevent hernias
Or in combination with the prosthetic mesh and muscle flaps
Attach mesh to the sacrum, coccyx, posterior iliac wings posteriorly and to the costal
margin anteriorly and laterally to the iliac crest and abdominal fascia
Use omentum or rectus abdominus internally to prevent contact between the internal
viscera and the mesh
Others options include
TFL
Rectus femoris
Gracilis
Sartorius
Vastus lateralis
Free tissue transfer
LATERAL DEFECTS
resection of all or part of the hemipelvis
depends on the extent and location of the tumour
smaller defects with a stable pelvis can be covered with local or free muscle transfer
only
larger defects usually require amputation of the lower limb with extensive resection of
the pelvis and soft tissues
HEMIPELVICECTOMY
 radical requires resection proximal to sacroiliac joint
 conservative involves preservation of part of the iliac bone
 if tumour is in the groin or iliac fossa then an anterior flap is best
Posterior flap
based on gluteal vessels and gluteus maximus
indications
1. primary tumour of the innominate bone or femur that have invaded the hip
joint
2. tumours of the upper thigh that extend through the obturator foramen into
the pelvis
3. anterior pelvic wall tumours
incisions start 5cm proximal and 2 cm medial to the ASIS
this incision follows the inguinal ligament to the pubic symphysis
posterior incision past to the greater tuberosity into the gluteal fold and around the
perineum and upper thigh to meet the first
divide the rectus and abdominal wall muscles
the common iliac vessels divided as are the branches of the internal iliac vessels
posteriorly the gluteal fascia is divided and the gluteal and TFL raised on their
pedicles
the nerves of the lower limb divided as is psoas
pubic symphysis, sacral nerve roots, pelvic diaphragm and sacroiliac joint is divided
the muscle then sutured to the anterior abdominal
fascia
Anterior flap
primary indication are tumours that involve the upper thigh and buttock
Based on the rectus femoris muscle and perforators from the LCFA and
superficial femoral arteries
incisions 2cm proximal and posterior to ASIS, parallels the inguinal ligament to pubic
tubercle
longitudinal incisions posterior medially and posterior laterally and joined by a
transverse incision above the patella
laterally incision parallels the iliac wing, then extends along the lateral aspect to the
quadriceps insertion superior to the patella
release all the muscular attachments
deepen the anterior incision and raise the anterior myocutaneous flap based on the
perforators of vastus lateralis and rectus femoris (SFA)
approximate the quadraceps fascia to the sacrum, quadratum lumborum, levator ani
closure over drains
INTERNAL HEMIPELVECTOMY
 involves resection of the innominate bone and preservation of the lower
extremity
 incision follow iliac crest posteriorly and then posterior-laterally down the leg
 variable amount of bone and soft tissue resection
 hip joint reconstruction, local free tissue reconstruction
POSTERIOR DEFECTS
 Usually result of resection of primary and secondary tumour resection
 Complicated by injuries to the nerves to the rectum, bladder, and lower extremities
o Resection below S3 urinary continence is maintained
o If at S1, pelvic stability is maintained
o If S1 and S2 is resected then bladder function is compromised
 Investigations
CT
MRI
CXR
Bone scan
Plain xrays of the lumbo-sacral spine
Reconstruction
 Gluteus maximus is the workhorse flap