{"id":1300,"date":"2021-01-21T10:16:19","date_gmt":"2021-01-20T21:16:19","guid":{"rendered":"https:\/\/tryitdemo.com\/vsa\/?p=1300"},"modified":"2021-01-21T10:16:21","modified_gmt":"2021-01-20T21:16:21","slug":"the-role-of-hemipelvectomy-a-case-study","status":"publish","type":"post","link":"https:\/\/tryitdemo.com\/vsa\/the-role-of-hemipelvectomy-a-case-study\/","title":{"rendered":"THE ROLE OF HEMIPELVECTOMY IN DEFINITIVE AND PALLIATIVE TREATMENT OF PERIPELVIC NEOPLASIA: A CASE STUDY"},"content":{"rendered":"\t\t
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GRACE KAEMPER<\/strong>
BVScV student<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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INTRODUCTION<\/strong><\/p>\n

Hemipelvectomy is a surgical procedure involving removal of the hemipelvis and corresponding hindlimb.\u00a0 It can be classi\ufb01ed as total or subtotal, where subtotal has three further subtypes: mid-to-cranial, mid-to-caudal and caudal (Barbur et al. 2015).<\/span><\/p>\n

There is a paucity of veterinary literature detailing both technical and clinical aspects of hemipelvectomy.\u00a0 One study presents hemipelvectomies as \u201ccomplex, aggressive surgical procedures\u201d with a high risk of intraoperative complications and \u201ca slower return to ambulation than amputation\u201d (Kramer et al. 2008).\u00a0 There is a need to challenge this commonly held perception in the veterinary industry, and the purpose of this case report is to present hemipelvectomy as a viable treatment option for a range of otherwise inaccessible tumours.<\/span><\/p>\n

This case study examines three dogs that underwent hemipelvectomy in 2018 at a single veterinary specialist hospital in Auckland.\u00a0 Two dogs presented with osteosarcoma of the proximal femur and ilium respectively, and the third was diagnosed with a peripheral nerve sheath tumour (PNST) of the sciatic nerve.\u00a0 In all three cases, the location of the tumour rendered standard limb amputation (coxofemoral disarticulation) insu\ufb03cient for primary tumour control.\u00a0 Therefore, a hemipelvectomy was required to obtain appropriate surgical margins.<\/span><\/p>\n

All dogs were followed from diagnosis and surgery, through to recovery, to examine both the oncologic and functional outcomes.\u00a0 See Table 1 for a summary of the three cases.<\/span><\/p>\n

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HEMIPELVECTOMY PROCEDURE<\/strong><\/div>\n
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Anaesthesia protocols were determined at the discretion of the surgeon (two surgeons performed three surgeries).\u00a0 A similar anaesthesia protocol was used in all three cases.\u00a0 Dogs were pre-medicated I\/V with 3 \u00b5g\/kg fentanyl (Fentanyl Citrate Injection 500\u00b5g; Hospira New Zealand Ltd, Auckland, NZ) or 3 \u00b5g\/kg remifentanil (ULTIVA; Pharmacy Retailing Ltd, Auckland, NZ), which was followed by anaesthetic induction using I\/V 0.25 mg\/kg diazepam (Ilium Diazepam; Ethical Agents Ltd, Auckland, NZ) and propofol (Fresofol 1%; Fresenius Kabi, Auckland, NZ) to e\ufb00ect.\u00a0 A constant rate I\/V infusion (CRI) of lidocaine (Lopaine 2%, Ethical Agents Ltd, Auckland, NZ), ketamine (Ketaset 10%, Zoetis New Zealand Ltd, Auckland, NZ) and fentanyl\/remifentanil (depending on the pre-medication) and I\/V \ufb02uid therapy with lactated Ringer\u2019s solution at 10 mL\/kg were given for the duration of the procedure and recovery.\u00a0 In two cases, 0.1 mg\/kg morphine (DBL Morphine Sulphate 5 mg\/mL Injection, Hospira) was given epidurally for additional analgesia.<\/div>\n
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The dogs were placed in lateral recumbency with a hanging leg preparation and an anal purse string suture was placed.\u00a0 The surgical technique for all three cases was similar and based on the hemipelvectomy method described by Barbur et al. (2015).\u00a0 A ventral approach was initially used with elevation of the sartorius, pectineus, gracilis, and adductor magnes et brevis muscles from their origin.\u00a0 This allowed isolation, ligation, and transection of the femoral artery and vein, and the obturator nerve.\u00a0 Pubic and ischial osteotomies were performed.\u00a0 Further muscle elevations exposed the ventral aspect of the sacroiliac joint, which was then disarticulated.\u00a0 The limb was then adducted, and the approach changed to dorsal.\u00a0 The sciatic nerve was isolated and transected.\u00a0 The ilium was freed by elevating its muscle and soft tissue attachments.\u00a0 The sacrotuberous ligament and dorsal sacroiliac ligament were incised to free the ilium from the sacrum and to allow removal of the hemipelvis and ipsilateral limb.\u00a0 The pelvic diaphragm was reconstructed during closure by approximating the remaining musculature.\u00a0 The subcutaneous tissue and skin were closed routinely to minimise tension (Barbur et al. 2015).\u00a0 A Jackson Pratt drain was placed before closure.\u00a0 All resected tissues were submitted for histopathology.<\/div>\n
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Any differences peculiar to the individual cases are discussed below.<\/div>\n<\/div>\n<\/div>\n

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CASE ONE<\/strong><\/p>\n

A 13-year-old, female, spayed Labrador Retriever presented with acute left hindlimb lameness of 10 days\u2019 duration.\u00a0 Radiographs revealed a pathological fracture of the proximal left femur with suspected neoplastic involvement of the ipsilateral coxofemoral joint.\u00a0 Thoracic radiographs showed a 5 mm-diameter, rounded, soft-tissue nodule in the caudodorsal aspect of the right caudal lung lobe.\u00a0 De\ufb01nitive tissue sampling of the pulmonary nodule was not obtained, and both benign and malignant considerations were given during clinical decision making.\u00a0 An abdominal ultrasound identi\ufb01ed a bilobed, di\ufb00usely heterogenous, soft-tissue mass of 31 mmx 12 mm e\ufb00acing the left adrenal gland, and mild left medial iliac lymphadenopathy.\u00a0 Preoperative biopsy of the fracture site was not pursued, as treatment was with palliative intent.<\/p>\n

A subtotal mid-to-cranial hemipelvectomy with concurrent amputation of the left pelvic limb was performed, utilising an osteotomy of the ilium caudal to the sacrum, osteotomy of the pubis within the obturator foramen, and osteotomy of the cranial ischium.\u00a0 Soft tissue dissection was performed outside the muscular compartment containing the fracture, such that the fracture haematoma and tumour were not encountered during surgery.\u00a0 Haemostasis was achieved with an electrothermal vessel sealing device (Ligasure; Medtronic Corporate ANZ, Auckland, NZ) and no complications arose during surgery.<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t

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Fig.1\u00a0<\/em><\/span>Dorsoventral radiograph of the pelvis of a Labrador Retriever taken 10 weeks after hemipelvectomy surgery as palliative treatment for osteosarcoma of the left proximal femur and acetabulum.\u00a0 There is an aggressive monostotic lesion of the right ischium with motheaten lysis, heterogenous sclerosis and irregular periosteal new bone formation.<\/i><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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Histopathology identi\ufb01ed the proximal femoral\/acetabular malignancy as an osteosarcoma with haemorrhage and necrosis.\u00a0 Surgical margin assessment revealed no neoplastic cells within 40 mm of the inked margins.<\/span><\/p>\n

The dog was strongly ambulatory following surgery and was discharged from hospital the day following her hemipelvectomy.\u00a0 The functional outcome, as reported by the owner, was excellent for 10 weeks after surgery.\u00a0 At that time, the dog developed acute non-ambulatory paresis and urinary incontinence.\u00a0 Neurologic examination was consistent with a painful L7-S3 lesion.\u00a0 Radiographs revealed motheaten lysis and heterogeneous sclerosis of the right ischium, and further pulmonary nodules (Figure 1).\u00a0 Advanced imaging and tissue biopsy were declined, but distant metastasis (spine and lungs) was suspected.\u00a0 The dog was discharged with analgesia provided by 400 mg gabapentin (Neurontin; P\ufb01zer New Zealand, Auckland, NZ) and 37.5 mg carprofen (Rimadyl; Zoetis New Zealand Ltd, Auckland, NZ) both given orally twice daily, but was euthanised due to lack of clinical improvement.<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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CASE TWO<\/strong><\/p>\n

An 11-year-old, male, neutered Sta\ufb00ordshire Bull Terrier presented with acute, weight-bearing lameness of the left hind limb of 10-days duration.\u00a0 Pain and soft-tissue swelling in the region of the left ilial body; a rectally palpable ilial mass; and atrophy of the left gluteal and quadriceps muscles were identi\ufb01ed.\u00a0 Incisional biopsy of the soft-tissue component of the mass was consistent with osteosarcoma of the left ilial body.\u00a0 Staging using computed tomography (CT) of the thorax, abdomen and pelvis identi\ufb01ed likely pulmonary metastasis and metastasis to the left sacral lymph node, as well as the aggressive lesion in the ilial body (Figure 2).\u00a0 The decision was made to perform a hemipelvectomy for palliative therapy along with adjunctive I\/V chemotherapy with carboplatin (DBL Carboplatin Injection; P\ufb01zer New Zealand, Auckland, NZ) at 300 mg\/m2 at 3-weekly intervals.<\/p>\n

A left total hemipelvectomy was performed, utilising osteotomies of the pubis, ischium, and left sacrum.\u00a0 A sacral lymph node was also removed.\u00a0 Blood vessels were ligated with 2\/0 PDS.\u00a0 No complications arose during surgery.<\/p>\n

Histopathology of the amputated limb and hemipelvis con\ufb01rmed the diagnosis of osteosarcoma.\u00a0 Neoplastic cells were present in the sacral tissue hence clean surgical margins were not obtained.<\/p>\n

The dog appeared bright and comfortable after surgery and was strongly ambulatory the day of surgery.\u00a0 He was discharged 3 days later.\u00a0 The dog was still alive 13 months later, and although the dog was not restaged, no new abnormalities were detected on physical exam.\u00a0 Limb function, as subjectively assessed by both the owner and veterinarian, was excellent, though the dog was unwilling to jump.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t

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Figure 2a<\/figcaption>\n\t\t\t\t\t\t\t\t\t\t<\/figure>\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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Fig.2\u00a0Post-contrast computed tomography images of the pelvis of an 11-year-old Staffordshire Bull Terrier showing a large, multi-lobulated mass lesion (*) with soft tissue density and associated lysis and periosteal bone formation of the ilial body. The mass is compressing and displacing the rectum.<\/em><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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CASE THREE<\/strong><\/p>\n

A 9-year-old, male, neutered Cairn Terrier presented with an 8-month history of chronic, non-weightbearing lameness of the right hindlimb with severe neurogenic atrophy of the hamstring, gastrocnemius and cranial tibial muscle groups.\u00a0 Magnetic Resonance Imaging (MRI) identi\ufb01ed severe, nodular, isointense thickening of the right lumbosacral trunk (Figure 3a), sciatic nerve (Figure 3b) and proximal portion of the tibial nerve where it branched at the caudal aspect of the sti\ufb02e joint.\u00a0 The right seventh lumbar nerve root was thickened as it exited its intervertebral foramen.\u00a0 Samples of the nerve mass taken by ultrasound-guided \ufb01ne needle aspirate and tru-cut biopsy were analysed and a malignant peripheral nerve sheath tumour (PNST) was diagnosed.\u00a0 Staging using CT showed no evidence of metastasis.\u00a0 CT the likely extension of the PNST from the sciatic nerve to the lumbosacral trunk and sixth (L6) and seventh (L7) lumbar nerve roots.<\/p>\n

A subtotal cranial hemipelvectomy was performed with osteotomies at the ischium, pubis and right lateral wing of the sacrum to expose the sacral plexus.\u00a0 A right hemilaminectomy of L6 and L7 was performed to expose the spinal canal.\u00a0 The L6 and L7 nerve roots showed gross thickening and were transected as far proximally as possible, while the \ufb01rst and second sacral nerve roots appeared normal and were resected at the level of their foramina.\u00a0 Nerves were anaesthetised with lignocaine prior to transection.\u00a0 Blood vessels were ligated with 3\/0 PDS.<\/p>\n

Histopathology of the amputated limb, hemipelvis, and nerve roots revealed a poorly di\ufb00erentiated sarcoma (most consistent with peripheral nerve sheath tumour) that largely e\ufb00aced the sciatic nerve and extended into the L7 nerve root.\u00a0 Polyradiculoneuritis was also present histopathologically.\u00a0 Surgical margins appeared clean, but with only a narrow margin of 3 mm in the L7 nerve root.<\/p>\n

The dog recovered well from the hemipelvectomy and was able to walk well both with and without sling assistance 1 day after surgery.\u00a0 He was discharged 3 days after the operation.\u00a0 Four months after surgery, the owner subjectively scored the dog\u2019s return to function as 9 on a 10-point scale.\u00a0 The dog was described as mobile, able to navigate stairs, swim, and waswalked twice daily without appearing painful.\u00a0 However, the owner reported a slight loss in stamina and that the dog could no longer jump upwards.\u00a0 Twelve months post-operatively, he was reported as happy and healthy.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t

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Fig.3\u00a0Post-contrast sagittal magnetic resonance images of the right hindlimb of a Cairn Terrier with an 8-month history of non-weightbearing lameness showing (a) severe, nodular isointense thickening at the level of the sacral plexus (red arrows) and (b) the same nerve mass affecting the sciatic nerve and proximal tibial nerve (red arrows). a=tensor fascia latae; b=rectus femoris; c=vastus intermedius; d=adductor magnus et brevis; e=semitendinosus; f=gluteal muscles.<\/em><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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Table 1.  Summary of presenting signs, treatment, outcome and diagnosis of three dogs that <\/i><\/font>underwent hemipelvectomy for palliative treatment of peripelvic neoplasia.<\/i><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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DISCUSSION<\/strong><\/p>\n

Hemipelvectomy is a technically challenging, but very versatile surgical technique, with broad applications to various neoplastic conditions of the hemipelvis and its surrounding anatomy.\u00a0 All dogs in this study achieved either microscopic or biologic control of their local disease.\u00a0 That is, two dogs had clean surgical margins, while the dog with dirty surgical margins has shown no evidence of local tumour recurrence in the past 13 months.\u00a0 Although the dogs all had markedly di\ufb00erent presentations and diagnoses, the one surgical modality was used e\ufb00ectively in all three cases.<\/p>\n

All three dogs in this study presented with pain and severe lameness as their predominant symptoms.\u00a0 Therefore, the primary objective of treatment was to immediately reduce or eliminate the pain associated with their tumour.\u00a0 Hemipelvectomy was e\ufb00ective in relieving the tumour-associated pain in all three dogs, providing a high quality of life within 12\u201324 hours in all dogs, even in a palliative setting.\u00a0 Other analgesic strategies for pathologic neoplastic pain have low success and weren\u2019t viable alternatives for these cases (Fan et al. 2007, Mathews 2008).<\/p>\n

Hemipelvectomy was also the most appropriate oncologic treatment for these dogs, o\ufb00ering the best chance of survival compared to other single-modality or neoadjuvant treatments (Szewczyk et al. 2015).\u00a0 Osteosarcomas are highly malignant with rapid metastasis, therefore the most e\ufb00ective treatment is combining surgery, single agent chemotherapy and radiotherapy (Szewczyk et al. 2015).\u00a0 Similarly, surgery is the mainstay of treatment for peripheral nerve sheath tumours, although survival times are enhanced with adjunctive radiation therapy (Lacassagne et al. 2018).\u00a0 The hemipelvectomy also removed the source of the dog\u2019s pain, providing a high quality of life, even in a palliative setting.<\/p>\n

Owner satisfaction after the hemipelvectomy was high, as was clinical outcome and return to function.\u00a0 This suggests that althoughthe hemipelvectomy is an invasive procedure, it does not deserve the stigma of being a last resort, poor-outcome surgery.\u00a0 These \ufb01ndings are mirrored by a recent study that states \u201cperioperative complications were infrequent, with patient recovery and long-term function no di\ufb00erent than described for pelvic limb amputation\u201d (Bray et al. 2013).<\/p>\n

Intraoperative complications \u2013 most importantly intraoperative haemorrhage, accidental dissection of nerves, and rectal or urethral damage \u2013 are considered low risk as long as care is taken during the surgical approach and dissection (Bray et al. 2013).\u00a0 No complications were seen in these cases, partly due to rigorous pre-operative planning and preparation.\u00a0 The tumours were mapped using CT to plan the surgical approach, cross-matched fresh whole blood was ready for transfusion if required, and surgeons had clear knowledge of the relevant regional anatomy.\u00a0 In Case 3, resection of the \ufb01rst and second sacral nerve roots involved potential disruption of the right pudendal nerve.\u00a0 This didn\u2019t appear to adversely a\ufb00ect the dog, and function of the perineal region was maintained post-operatively.<\/p>\n

While early post-operative outcome was excellent in all cases, medium-term outcome was variable.\u00a0 In this study, one dog was euthanised due to tumour-related clinical progression, while the two other dogs were still alive 386 days and 379 days after surgery.\u00a0 Bray et al. demonstrated a median disease free interval of 49\u2013126 days and 226 days for osteosarcoma and soft tissue sarcoma respectively, with 50% survival at 1 year (Bray et al. 2013).\u00a0 Multiple studies document a curiously high rate of incomplete tumour resection due to tumour size and location e.g. medial extension of PNST (Bray et al. 2013, Barbur et al. 2015).\u00a0 In\ufb01ltrated surgical margins reduce the time to recurrence and reduce median survival times (Lacassagne et al. 2018).\u00a0 In this study, the histopathologic tumour margin had no correlation to clinical or oncologic outcome.\u00a0 Due to the di\ufb03culty in obtaining clean surgical margins, one could question whether this invasive and expensive procedure is justi\ufb01able, especially in cases where there is already metastasis.\u00a0 The owner\u2019s goals must be discussed prior to surgery.\u00a0 In this case study, a survival time of months to years was preferable to immediate euthanasia, the only alternative due to the degree of welfare impairment.<\/p>\n

Based on our experience, and the clinical outcomes detailed in this study, we propose a paradigm shift involving hemipelvectomy.\u00a0 Rather than seeing the surgery as a radical, \u2018heroic\u2019 treatment, it should instead be considered as much for palliative therapy in cases such as these with advanced disease.\u00a0 While the surgery is technically challenging, and attention to perioperative patient care is paramount, hemipelvectomy patients in our experience have exceptional recoveries and return to function, with little di\ufb00erence to pelvic limb disarticulation (Dickerson et al. 2015).\u00a0 Although case reports and larger retrospective studies are still few and far between, they are increasingly recognising the role of hemipelvectomy in the treatment of a range of pelvic neoplasms (Bray et al. 2013, Ens 2017, Vinayak 2018).\u00a0 This novel treatment may not be novel for long.<\/p>\n

ACKNOWLEDGEMENTS<\/strong><\/p>\n

Special thanks to Dr. Alastair Coomer and Dr. Richard Jerram at VSA for use of their cases and support in writing the report.<\/p>\n

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References:
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Barbur LA, Coleman KD, Schmiedt <\/b>CW, Radlinksy MG. <\/b>Description of the anatomy, surgical technique, and outcome of hemipelvectomy in 4 dogs and 5 cats. Veterinary Surgery 44, 613\u2013626, 2015<\/i><\/p>\n

Bray JP, Worley DR, Boston SE, <\/b>Romanelli G, Liptak JM, Scase TJ. <\/b>Hemipelvectomy: Outcome in 84 dogs <\/i>and 16 cats. A veterinary society of <\/i>surgical oncology retrospective study. <\/i>Veterinary Surgery 43, 27\u201337, 2013<\/i><\/p>\n

Dickerson VM, Coleman KD, Ogawa <\/b>M, Saba CF, Cornell KK, Radlinsky <\/b>MG, Schmiedt CW. <\/b>Outcomes of dogs <\/i>undergoing limb amputation, owner <\/i>satisfaction with limb amputation <\/i>procedures, and owner perceptions <\/i>regarding postsurgical adaptation: <\/i>64 cases (2005\u20132012). Journal of the <\/i>American Veterinary Medical Association <\/i>247, 786\u2013792, 2015<\/i><\/p>\n

Ens MTB, Stocco MB, Gomes LG, Soares <\/b>LMC, Dower NMBD, Menegassi <\/b>CC, Guimar\u00e3es MD, Colodel EM, de <\/b>Souza RL. <\/b>Total hemipelvectomy in a <\/i>cat with osteoblastic osteosarcoma. Acta <\/i>Scientiae Veterinariae 45, 190, 2017<\/i><\/p>\n

Fan TM, de Lorimier LP, O\u2019Dell-<\/b>Anderson K, Lacoste HI, Charney <\/b>SC. <\/b>Single-agent pamidroate for palliative therapy of canine appendicular <\/i>osteosarcoma bone pain. Journal of <\/i>Veterinary Internal Medicine 21, 431\u2013439, <\/i>2007<\/i><\/p>\n

Kramer, A, Walsh, PJ, Seguin, B. <\/b>Hemipelvectomy in dogs and cats: <\/i>technique overview, variations, and <\/i>description. Veterinary Surgery 37, <\/i>413\u2013419, 2008<\/i><\/p>\n

Lacassagne K, Hearon K, Berg J, S\u00e9guin <\/b>B, Hoyt L, Byer B, Selmic LE. <\/b>Canine <\/i>spinal meningiomas and nerve sheath <\/i>tumours in 34 dogs (2008\u20132016): <\/i>distribution and long-term outcome <\/i>based upon histopathology and treatment <\/i>modality. Veterinary and Comparative <\/i>Oncology 16, 244\u2013351, 2018<\/i><\/p>\n

Mathews KA. <\/b> <\/span>Neuropathic pain in dogs <\/i>and cats: If only they could tell us if they <\/i>hurt. Veterinary Clinics: Small Animal <\/i>Practice 38, 1365\u20131414, 2008<\/i><\/p>\n

Szewczyk M, Lechowski R, Zabielska <\/b>K. <\/b> <\/span>What do we know about canine <\/i>osteosarcoma treatment: review. <\/i>Veterinary Research Communications 39, <\/i>61\u201367, 2015<\/i><\/p>\n

Vinayak A, Worley DR, Withrow <\/b>SJ, Adams DS, Powers BE.<\/b> <\/span> <\/span>Dedifferentiated chondrosarcoma in the <\/i>dog and cat: a case series and review of <\/i>the literature. American Animal Hospital <\/i>Association 54, 50\u201359, 2018 <\/i><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t

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Author:

GRACE KAEMPER, BVScV student<\/span><\/p>Companion Quarterly: Official Newsletter of the Companion Animal Veterinarians Branch of the NZVA | Volume 31 No 2 | June 2020<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t

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GRACE KAEMPERBVScV student INTRODUCTION Hemipelvectomy is a surgical procedure involving removal of the hemipelvis and corresponding hindlimb.\u00a0 It can be classi\ufb01ed as total or subtotal, where subtotal has three further subtypes: mid-to-cranial, mid-to-caudal and caudal (Barbur et al. 2015). There …<\/p>\n

THE ROLE OF HEMIPELVECTOMY IN DEFINITIVE AND PALLIATIVE TREATMENT OF PERIPELVIC NEOPLASIA: A CASE STUDY<\/span> Read More \u00bb<\/a><\/p>\n","protected":false},"author":11,"featured_media":1301,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"site-sidebar-layout":"default","site-content-layout":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"disabled","adv-header-id-meta":"","stick-header-meta":"default","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","footnotes":""},"categories":[9],"tags":[],"class_list":["post-1300","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-cases"],"acf":[],"yoast_head":"\nCase Study: The Role of Hemipelvectomy | Veterinary Specialists Auckland<\/title>\n<meta name=\"description\" content=\"Hemipelvectomy is a surgical procedure involving removal of the hemipelvis and corresponding hindlimb. 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