Anatomical Considerations and Plastic Surgery Reconstruction Options of Sacral Chordoma Resection

Abstract

Introduction Chordomas are slow-growing malignant bone tumors arising from remnant embryonic notochord cells with predilection for the sacrum. They rarely metastasize, and early surgical resection with clear margins is the treatment of choice followed by plastic surgery reconstruction supplemented with adjuvant radiotherapy based on the local treatment protocol or in cases with a contaminated surgical field. Aim The aim of the present study is to present our experience in surgical management of sacral chordomas and propose a surgical reconstruction algorithm considering anatomical parameters after partial or total sacrectomy. Materials and methods Twenty-seven patients with sacral chordomas were treated in our Orthopaedic Surgery Department between January 1997 and September 2022, and 10 of them had plastic surgery reconstruction. Patients were divided into groups based on the type of sacrectomy, sacrum anatomical vascular or neural variations, partial or total, and the type of soft tissue reconstruction. The postoperative complications and the functional outcomes in each patient were assessed. Results Bilateral gluteal advancement flaps or gluteal perforator flaps are the first choice in patients with partial sacrectomy, intact gluteal vessels, and without preoperative radiotherapy followed by transpelvic vertical rectus abdominis myocutaneous flap or free flaps in those patients with near total sacrectomy and preoperative radiation therapy. Conclusion There are four reliable options for patients after sacral chordoma resection: direct closure, bilateral gluteal advancement flaps, transpelvic vertical rectus abdominis myocutaneous flaps, and free flaps. Each time, tumor-free margins and a good reconstructive plan according to the defect and patient characteristics are mandatory.

Keywords: advancement flap; chordomas; partial sacrectomy; radiotherapy (rt); sacral tumors.

Figure 1. VRAM flap dissection

VRAM: Vertical Rectus Abdominis myocutaneous flap

Figure 2. VRAM insetted through the pelvis to the defect area

VRAM: Vertical rectus abdominis myocutaneous flap

Figure 3. Deepithelialization of VRAM skin and final insetting of the flap

VRAM: Vertical rectus abdominis myocutaneous flap

Figure 4. Bilateral gluteal advancement v-y flaps. Note the venous stasis to the L side

Figure 5. Postoperative result without recurrence after a year

Figure 6. Medical leeches were used to encounter the venous stasis of the flap

Figure 7. Our surgical algorithm for plastic surgery reconstruction after sacral chordoma resection

VRAM: Vertical rectus abdominis myocutaneous flap