Pediatric lower extremity sarcoma reconstruction: A review of limb salvage procedures and outcomes

Use of pedicled flaps after oncologic resections in pediatric patients

The aim of this study is to review the indications of pedicled flaps and analyze the results. A observational retrospective study of under 18-year-old oncology patients who required reconstructive surgery with pedicled flaps between 2011 and 2022 was performed. Demographic and clinical variables, indications, complications, and outcomes were collected. 236 patients were reviewed and 13 met inclusion criteria, eight girls and five boys (mean age: 10.6 years). Indications were Ewing's sarcoma (5), osteosarcoma (5), neuroblastoma, desmoid tumor, and neurofibroma. Preoperative PET-CT, MRI and bone scintigraphy were performed. The flaps were used on costal and extremity reconstruction: latissimus dorsi (5), pectoralis (2), medial gastrocnemius (2), combined latissimus dorsi, trapezius and serratus muscle, biceps femoris, fascio-neuro-cutaneous saphenous and cutaneous advancement-rotation. Two were performed on allograft and eight on prosthesis. All allowed immediate and complete closure. Six patients received intraoperative radiotherapy. One flap infection and two vascular complications were reported, a total necrosis, which required a new flap, and a partial necrosis, treated with a local plasty. Chemotherapy was resumed after 21 days (15-31). Mean follow-up time was 5.34 years. Flaps are an effective therapeutic option allowing reconstruction of large defects after pediatric oncologic surgeries. The most frequent complication was vascular.

The evolution of pediatric soft-tissue free flap reconstruction of the lower extremity after oncologic resection: A 30 year experience

INTRODUCTION

Limb salvage has become the standard of care for lower extremity tumors because of improvements in adjuvant treatments and reconstructive techniques. While there is literature assessing pediatric lower extremity free flap reconstruction in the setting of trauma, there is a paucity of literature that analyzes oncologic free flap reconstruction in this patient population. We report our long-term experience and evolution of care for lower extremity oncologic free flap reconstruction in pediatric patients.

METHODS

This is a retrospective case series of all patients ≤18 years of age who underwent oncologic soft-tissue microvascular reconstruction of the lower extremity, from 1992 to 2021. Data were collected for patient demographics, oncologic treatment, operative details, and post-operative outcomes. Functional outcomes were assessed by weight bearing status, ambulation, and participation in activities-of-daily-living (ADLs), and musculoskeletal tumor society (MSTS) scores.

RESULTS

Over the 30-year study period, inclusion criteria were met by 19 patients (11 males, 8 females) with a mean age of 13.8 years and a mean follow-up of 5.3 years. At last follow-up, 13 patients (68.5%) were alive. The most common pathology was osteogenic sarcoma (13 patients, 68.5%). Sites of reconstruction were the hip (n = 1), thigh (n = 5), knee (n = 4), leg (n = 7), and the foot (n = 2). The most commonly used flaps were latissimus dorsi (n = 8), gracilis (n = 4), and anterolateral thigh ± vastus (n = 4). Postoperative complications occurred in nine patients (43%). Overall flap success rate was 95%. At latest follow-up, ambulation without assistive device was obtained in 11 patients (58%), full weight bearing was achieved by 13 patients (68.5%), and ADLs could be performed independently by 13 patients (68.5%). Mean MSTS score was 23.1/30.

CONCLUSION

Microvascular reconstruction for oncological lower extremity defects in the pediatric population has high limb salvage rates and good functional outcomes.

Free Vacularized Fibula Flap for Septic Bone Defects of the Lower Limb

Free fibula flap (FFF) is one of the reconstructive techniques to treat bone defects, although in septic conditions there are some limitations that have made it less popular. We present our experience with FFF for the reconstruction of lower limb infectious bone defects. From September 2015 to January 2020, 10 patients underwent reconstruction with FFF without rigid internal fixation of septic bone defects of the lower extremities. Demographic, clinical, and operative data were retrospectively collected. All the flaps survived and consolidated. The only major complication was a stress fracture of a fibula that required osteosynthesis. Median time to consolidation and full weight-bearing was 2.5 and 9.8 months, respectively. Bipedal gating was achieved in all the patients, 7 of them without walking aids. Despite it has some limitations and technical difficulties, in our experience FFF is an effective and reliable option in the reconstruction of septic bone defects of the lower limb.

Operative Treatment and Outcomes of Pediatric Patients with an Extremity Bone Tumor: A Secondary Analysis of the PARITY Trial Data

BACKGROUND

Osteosarcoma and Ewing sarcoma are the 2 most common primary bone sarcomas, occurring predominantly in pediatric patients, with the incidence of osteosarcoma correlating with periods of peak bone-growth velocity. Although survival outcomes have plateaued over the past several decades, ongoing treatment advances have improved function, decreased infection rates, and improved other clinical outcomes in patients with bone tumors. Recently, the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial addressed the serious problem of surgical site infection (SSI) and the lack of consensus regarding the appropriate prophylactic postoperative antibiotic regimen. The objective of the present secondary analysis of the PARITY trial was to characterize the modern treatment and surgical and oncologic outcomes of pediatric patients with bone tumors at 1 year postoperatively.

METHODS

The PARITY trial included patients ≥12 years old with a bone tumor or soft-tissue sarcoma that was invading the femur or tibia, necessitating osseous resection and endoprosthetic reconstruction. This pediatric subanalysis of the PARITY trial data included all PARITY patients ≤18 years old. As in the main PARITY study, patients were randomized to either a 5-day or 1-day course of postoperative antibiotic prophylaxis. The primary outcome measure was the development of an SSI within 1 year, and secondary outcomes included antibiotic-related adverse events, unplanned additional operations, local recurrence, metastasis, and death.

RESULTS

A total of 151 patients were included. An adjudicated SSI occurred in 27 patients (17.9%). There was no difference in the rate of any SSI between the 5-day and 1-day antibiotic groups (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.4 to 1.9; p = 0.82). Antibiotic-related complications occurred in 13 patients (8.6%), with no difference noted between groups (HR, 0.46; 95% CI, 0.2 to 1.4; p = 0.18). A total of 45 patients (29.8%) required a return to the operating room within the first postoperative year, which corresponded with a 68.8% reoperation-free rate of survival at 1 year when accounting for competing risks. The most common reason for reoperation was infection (29 of 45; 64.4%). A total of 7 patients (4.6%) required subsequent amputation of the operative extremity, and an additional 6 patients (4.0%) required implant revision within 12 months. A total of 36 patients (23.8%) developed metastases, and 6 patients (4.0%) developed a local recurrence during the first postoperative year. A total of 11 patients (7.3%) died during the study period. There were no significant differences in oncologic outcomes between the 5-day and 1-day antibiotic groups (HR, 0.97; 95% CI, 0.5-1.8; p = 0.92).

CONCLUSIONS

There were no significant differences in surgical or oncologic outcomes between pediatric patients who underwent a 1-day versus 5-day antibiotic regimen following endoprosthetic reconstruction in the PARITY trial. Surgeons should be aware of and counsel patients and caregivers regarding the 30% rate of reoperation and the risks of infection (17.9%), death (7.3%), amputation (4.6%), and implant revision (4%) within the first postoperative year.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Donor-site morbidity of free fibula flap in pediatric patients: A systematic review and meta-analysis

The morbidity of free fibula flap (FFF) in pediatric patients has gained attention. Thus, we aimed to evaluate donor-site morbidity after FFF harvesting in pediatric patients and its relationship with age. A systematic literature search of databases for cross-sectional studies related to pediatric donor-site morbidity after FFF harvesting was performed. Two independent reviewers evaluated relevant article titles and abstracts to extract data regarding donor-site morbidity from each article. Fifteen studies were included in the meta-analysis that evaluated the rate of complications. Individual cases of ankle instability were divided into the 0-13- and 13-17-year-old groups. The Chi-square test was used to compare ankle instability between both groups. A logistic regression model was created to analyze the relationships between age and ankle instability/claw toe. Sixteen English articles published between 2007 and 2021 were included in the systematic review. Information on morbidities of 294 cases in which FFF was used was collected. The mean incidence rate of complications, instability, claw toe, and nerve injury were 19.3%, 12.9%, 5.9%, and 5.1%, respectively. Bivariate analysis showed that age was significantly correlated with the incidence of ankle instability but not with the incidence of claw toe. The Chi-square test showed that the incidence rate of ankle instability between the age groups was significantly different. Therefore, we recommend 14 years of age as a new predictive factor for ankle instability. Nevertheless, there is limited evidence in this field, and more pediatric research is needed to clarify these findings.

Surgical management of extremity rhabdomyosarcoma: A consensus opinion from the Children's Oncology Group, the European Pediatric Soft-Tissue Sarcoma Study Group, and the Cooperative Weichteilsarkom Studiengruppe

The treatment of extremity rhabdomyosarcoma remains a challenge due to several adverse prognostic factors frequently associated with this tumor site. The International Soft-Tissue Sarcoma Database Consortium (INSTRuCT) is a collaboration of the Children's Oncology Group Soft-Tissue Sarcoma Committee, the European Pediatric Soft-Tissue Sarcoma Study Group, and the Cooperative Weichteilsarkom Studiengruppe. The INSTRuCT surgical committee developed an internationally applicable consensus opinion document for the surgical treatment of extremity rhabdomyosarcoma. This document addresses surgical management, including biopsy, nodal staging, timing of therapy, resection and reexcision, reconstruction, and surgical approach at relapse.

How much is a leg worth following radical tumor resection in bone sarcomas? Literature review

Bone sarcomas of the lower extremities are rare malignancies occurring mostly amongst adolescents and young adults. Necessarily, the therapy conducted in sarcoma centers is multimodal and multidisciplinary. In certain cases, in a metastasis free situation with adequate therapy, an overall survival rate of 90% can be achieved. Two principal surgical procedures exit for the local control of the malignancy: 1. Limb salvage with biological with/or endoprosthetic reconstruction; and, 2. amputation with restoration of the function with exoprosthesis or endo-exoprosthesis. Currently, limb salvage procedures are performed in up to 95% of cases. In contrast, amputation is performed when the disease has reached an advanced stage or limb salvage has failed. Both of the surgical options have their risks and possible complications. According to the literature, there should be no significant difference between limb salvage and amputation with respect to long-term overall survival, overall quality of life, psycho-socio-economic outcomes, or patient satisfaction. An important advantage of limb salvage is greater everyday functionality. With the expanded indication of limb salvage and great survival rates, the cases of late complications in patients expecting to maintain their own leg continues to increase. In some cases, it requires multiple interventions, ranging from minor up to the most complex revisions, to maintain the functionality of the extremity. Despite the great costs, personal effort, and the possible complications, limb salvage could be a suitable method to achieve functionally beneficial outcomes and patient satisfaction in bone sarcomas of the lower extremities over the long-term even in cases involving complications.

Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient

Background. Lower extremity injuries in the pediatric population that are associated with Gustillo 3B/3C fractures require special consideration. Limb salvage should be attempted in the pediatric patient if at all possible, and oftentimes the soft tissue defect that is present over the bony fracture is substantial. The traditional algorithm used in the management of Gustillo 3B/3C fractures in plastic surgery, referred to as the reconstructive ladder, would recommend flap reconstruction with free tissue transfer in most cases because regional options are often unavailable or do not provide adequate coverage. Free tissue transfer procedures are extensive and necessitate a donor site; they often require multiple procedures and subsequent revisions. Furthermore, when concomitant injuries or medical conditions are present, a patient may not be an appropriate candidate for a free flap. Another option, however, does exist for the pediatric patient with a significant lower extremity injury that is often overlooked by the plastic surgeon. Several articles in the orthopedic literature describe the utility of temporary limb deformation to allow for soft tissue closure, with gradual correction of the bony deformity over time. Although the healing process for these procedures take several months, there is no need for extensive soft tissue reconstruction and the ultimate result is a leg that is functional with adequate coverage. This article reports a case where this type of bone and soft tissue reconstruction was performed in a patient with an excellent overall outcome. This technique could be useful in select cases as an option in pediatric lower extremity reconstruction.

Orthoplastic reconstruction in children: are the risk factors similar to those observed in adults?

Free flaps in the pediatric population are less common and when indicated the expectations to avoid amputation are high. The objective of this study is to describe indications and results of free flaps for limb reconstruction. Patients undergoing microsurgical free flaps in an orthopedic hospital were consecutively included in this cross-sectional study, from 2014 to 2020. Data regarding personal medical history, intraoperative microsurgical procedure and laboratory tests were collected. Patients under 18 years of age were included. Complications and free flap outcomes were observed during follow-up. This study included 23 free flaps in 23 patients with orthoplastic reconstruction. The free flap was performed as a reconstructive elevator concept. The most common indications were skin or bone defects caused by trauma (nine patients), tumor (six patients) and congenital pseudarthrosis of the tibia (four patients). The most indicated flap was a vascularized fibular flap in 10 patients, followed by an anterolateral thigh flap in 5 patients. Complications were observed in five patients. In total 93% of patients with inferior limb reconstruction walked at the final evaluation. Among risk factors studied, cases had a higher incidence of complications (P = 0.03) when only the superficial venous system was used. Free flaps in children are well-tolerated and indications are restricted to precise indications to provide alternatives to amputations and improve patient's function. We observed an increase in the incidence of complications when only superficial veins were used for free flap outflow in children.

Pedicled fibular transfer for biologic knee extensor tendon reinsertion following proximal tibial resection in pediatric osteosarcoma: Long-term outcomes

INTRODUCTION

Proximal tibial sarcoma resections result in a reconstructive challenge, necessitating joint and extensor mechanism reconstruction. The gait and functional outcomes for children reconstructed with a combination of megaprosthesis and pedicled fibular flap for extensor mechanism reconstruction, are presented.

METHODS

Four patients, aged 11-18 years old, were available for comprehensive analysis. The proximal tibial osteosarcoma was resected, and the reconstructive technique involved a megaprosthesis for the knee joint, used in combination with a pedicled fibula flap as a biologic structure for reinsertion of the knee extensor mechanism. Outcomes were measured with three-dimensional gait analysis and patient questionnaires.

RESULTS

Minor postoperative wound issues occurred in some patients, requiring debridement with skin grafting. One patient fractured their transferred fibula, requiring fixation. The follow up period ranged from 1.7 to 24 years postoperatively. The longevity and quality of reconstructions were strong, measured by both objective and patient-reported outcomes. All patients reported independent walking >500 m in the Functional Mobility Scale and rated their walking as a nine or 10 (out of 10) on the Functional Assessment Questionnaire. Knee society scoring revealed overall satisfaction rate of 75-80%. No patients required gait aids. The gait profile analysis revealed effective gait patterns, with patterns deviating 5.4-7° from "typical gait." Deviations >6.5° are considered abnormal.

CONCLUSION

The long-term results of combining a megaprosthesis with a pedicled fibula flap for extensor reinsertion, revealed a high level of independent function. The patients performed well, without the need for aids, and gait study evidence of minimal gait deviations.

The use of the fibula flap in post oncologic reconstruction of long bone in pediatric patients: A retrospective cohort study

BACKGROUND

Pediatric sarcomas are the most common malignancies of bones in childhood. With advances in adjuvant treatment, limb salvage surgery has become common, increasing the demand of skeletal reconstruction. Traditional practice included bone grafting and transport. Recently, microsurgical tissue transfer in pediatric patients has become a well-accepted practice, with the fibula as an ideal biologic construct for long bone reconstruction. We aim to assess the success rate of this operation, including flap survival, bony union, weight-bearing ambulation, and complications.

METHODS

We identified 10 pediatric patients who underwent reconstruction of long bones (femur, humerus, or tibia) with a free fibula flap from January 2015 to January 2020. All patients received neoadjuvant chemotherapy 4 weeks prior to the surgical procedure followed by adjuvant chemotherapy.

RESULTS

The average follow-up time was 15 months. We had no partial or total flap loss. Three of our patients passed away in the first post-operative year due to metastatic disease. In the remaining 7 patients, we had two long-term complications. The fibula of one patient did not exhibit hypertrophy, yet weight-bearing ambulation was achieved. The other patient had nonunion proximally that required bone grafting at 8 months post-operatively. After that, the same patient fractured her fibula and required surgical fixation. She was eventually able to achieve weight-bearing ambulation.

CONCLUSION

The vascularized fibula flap is a reliable tool for reconstruction in children. Flap survival is similar to that of adults. Complication rate is low compared to that for other forms of reconstruction.

Free flap reconstruction of sarcoma defects in the setting of radiation: a ten-year experience

Neoadjuvant treatment and surgical resection for sarcoma patients can often leave devastating wounds necessitating soft-tissue coverage in the form of free flaps. There is still debate as to the optimal flap for reconstruction of defects in irradiated fields. We aim to describe our experiences with free fasciocutaneous and free muscle flaps for sarcoma reconstruction in the setting of radiation therapy. A retrospective chart review was conducted encompassing all patients requiring soft-tissue reconstruction secondary to sarcoma resection from January 2010 to June 2019. Patient characteristics, flap viability and post-operative healing outcomes were all recorded and examined. In total, 49 patients who underwent 51 free-flaps were identified. Of these, 30 flaps were fasciocutaneous, while 21 were muscle-based. Most patients received pre-operative radiotherapy (76.5%), although these rates were not different between groups of flap type, and had no significant association with post-operative outcomes. Complication rates (31.3%) and re-operative rates (21.6%) were also comparable between flap types. Diabetes mellitus was significantly associated with delayed wound healing (p < .016), while the presence of peripheral vascular disease had a significant association with post-operative infection (p < .006). This study shows that free fasciocutaneous and free muscle-based flaps are both viable options for soft-tissue reconstruction demanded by sarcoma resection, even in the setting of radiation. Peripheral vascular disease and diabetes mellitus may confer increased wound complications.

Alterations in Muscle Architecture: A Review of the Relevance to Individuals After Limb Salvage Surgery for Bone Sarcoma

Osteosarcoma and Ewing's sarcoma are the most common primary bone malignancies affecting children and adolescents. Optimal treatment requires a combination of chemotherapy and/or radiation along with surgical removal when feasible. Advances in multiple aspects of surgical management have allowed limb salvage surgery (LSS) to supplant amputation as the most common procedure for these tumors. However, individuals may experience significant impairment after LSS, including deficits in range of motion and strength that limit function and impact participation in work, school, and the community, ultimately affecting quality of life. Muscle force and speed of contraction are important contributors to normal function during activities such as gait, stairs, and other functional tasks. Muscle architecture is the primary contributor to muscle function and adapts to various stimuli, including periods of immobilization-protected weightbearing after surgery. The impacts of LSS on muscle architecture and how adaptations may impact deficits within the rehabilitation period and into long-term survivorship is not well-studied. The purpose of this paper is to [1] provide relevant background on bone sarcomas and LSS, [2] highlight the importance of muscle architecture, its measurement, and alterations as seen in other relevant populations and [3] discuss the clinical relevance of muscle architectural changes and the impact on muscle dysfunction in this population. Understanding the changes that occur in muscle architecture and its impact on long-term impairments in bone sarcoma survivors is important in developing new rehabilitation treatments that optimize functional outcomes.

Overview of Wound Healing and Management

Wound healing is a highly complex chain of events, and although it may never be possible to eliminate the risk of experiencing a wound, clinicians' armamentarium continues to expand with methods to manage it. The phases of wound healing are the inflammatory phase, the proliferative phase, and the maturation phase. The pathway of healing is determined by characteristics of the wound on initial presentation, and it is vital to select the appropriate method to treat the wound based on its ability to avoid hypoxia, infection, excessive edema, and foreign bodies.