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Cohen Z, Plotsker E, Graziano F, Cordeiro P, Disa J, Mehrara B, Fabbri N, Azoury SC, Shahzad F. The evolution of pediatric soft-tissue free flap reconstruction of the lower extremity after oncologic resection: A 30 year experience. Microsurgery 2024; 44:e31130. [PMID: 37877296 PMCID: PMC11296888 DOI: 10.1002/micr.31130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 10/02/2023] [Accepted: 10/12/2023] [Indexed: 10/26/2023]
Abstract
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.
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Affiliation(s)
- Zack Cohen
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ethan Plotsker
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Francis Graziano
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter Cordeiro
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joseph Disa
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak Mehrara
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicola Fabbri
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery University of Pennsylvania
- Department of Orthopedic Surgery, University of Pennsylvania
| | - Farooq Shahzad
- Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY
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Immediate Versus Staged Soft Tissue Reconstruction After Soft Tissue Sarcoma Resection Has Similar Wound and Oncologic Outcomes. Ann Plast Surg 2021; 85:163-170. [PMID: 31913884 DOI: 10.1097/sap.0000000000002192] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. METHODS This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. RESULTS Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. CONCLUSIONS Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.
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Baysal Ö, Sağlam F, Akgülle AH, Sofulu Ö, Yiğit O, Şirin E, Erol B. Factors affecting postmusculoskeletal tumour surgery wound problem treatment with negative pressure wound therapy. Int Wound J 2020; 17:692-700. [PMID: 32065733 DOI: 10.1111/iwj.13326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/28/2020] [Accepted: 02/02/2020] [Indexed: 11/27/2022] Open
Abstract
The aim of the study is to investigate the risk factors identified in literature that have been associated with prolonged Negative Pressure Wound Therapy (NPWT). Our study included patients who developed local wound problems after bone or soft tissue sarcoma surgery with negative margin at our clinic between 2012 and 2018 and treated with NPWT. All patients were followed up of at least 6 months. Sex, albumin level, skin infiltration, type of wound problem, postoperative intensive care unit (ICU) requirement, and intraoperative blood loss were found to be influential factors on NPWT > 10 sessions. We conclude that treatment may be prolonged and the necessary precautions need to be taken in patients with an impaired preoperative nutritional condition, with intraoperative high amount of blood loss, and with long postoperative stays in the ICU as well as if the underlying cause for wound problem is an infection.
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Affiliation(s)
- Özgür Baysal
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Fevzi Sağlam
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Hamdi Akgülle
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Ömer Sofulu
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Okan Yiğit
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Evrim Şirin
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Bülent Erol
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
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Bowen CM, Landau MJ, Badash I, Gould DJ, Patel KM. Primary tumors of the hand: Functional and restorative management. J Surg Oncol 2018; 118:873-882. [DOI: 10.1002/jso.25202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/23/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Chase M. Bowen
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Mark J. Landau
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Ido Badash
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Daniel J. Gould
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
| | - Ketan M. Patel
- Division of Plastic and Reconstructive Surgery; Keck School of Medicine of the University of Southern California; Los Angeles California
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Lansu J, Groenewegen J, van Coevorden F, van Houdt W, van Akkooi ACJ, van Boven H, van de Sande M, Verheij M, Haas RL. Time dependent dynamics of wound complications after preoperative radiotherapy in Extremity Soft Tissue Sarcomas. Eur J Surg Oncol 2018; 45:684-690. [PMID: 30316565 DOI: 10.1016/j.ejso.2018.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/03/2018] [Accepted: 09/17/2018] [Indexed: 02/03/2023] Open
Abstract
AIMS The purpose of the study was to investigate the time dependent dynamics of wound complications and local control after preoperative radiotherapy (RT) in Extremity Soft Tissue Sarcomas (ESTS). PATIENTS & METHODS In this retrospective cohort study, all patients treated for an extremity sarcoma with pre-operative radiotherapy followed by surgery were identified from a prospectively maintained database. A wound complication (WC) was defined as any local complication of the surgical area requiring intervention, hospital readmission or significant extension of the initial admission period. RESULTS A total of 191 preoperatively irradiated ESTS patients were included in this study. WC was seen in 31% of the patients (n = 60). WC started after a median time of 25 days from surgery, with a median duration of 76 days. Adiposity, smoking and a lower extremity or superficial tumor localization were significantly correlated with an increased WC rate. Risk factors for a duration of WC ≥ 120 days are early development of WC (≤21 days after surgery) and smoking. Local control rates after 1, 3 and 5 years were 99%, 93% and 93%, respectively. CONCLUSION Approximately one-third of patients selected for preoperative RT develops a WC, typically in smoking, adipose patients with superficial tumor localizations in the lower extremity. Based upon the well-established superior long-term functional outcome, maintained excellent local control rates and the temporary nature of the WC issue, preoperative RT remains our preferred treatment. Although, in patients at high risk of WC, post-operative RT might be considered.
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Affiliation(s)
- Jules Lansu
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Jan Groenewegen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Frits van Coevorden
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Winan van Houdt
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | | | - Hester van Boven
- Department of Pathology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | | | - Marcel Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands.
| | - Rick L Haas
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands; Department of Radiation Oncology, LUMC, Leiden, the Netherlands.
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Chan LWM, Imanishi J, Grinsell DG, Choong P. Preoperative Radiotherapy and Wide Resection for Soft Tissue Sarcomas: Achieving a Low Rate of Major Wound Complications with the Use of Flaps. Results of a Single Surgical Team. Front Surg 2018; 4:79. [PMID: 29404337 PMCID: PMC5786513 DOI: 10.3389/fsurg.2017.00079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 12/21/2017] [Indexed: 11/13/2022] Open
Abstract
Background Surgery in combination with radiotherapy (RT) has become the standard of care for most soft tissue sarcomas. The choice between pre- and postoperative RT is controversial. Preoperative RT is associated with a 32–35% rate of major wound complications (MWC) and 16–25% rate of reoperation. The role of vascularized soft tissue “flaps” in reducing complications is unclear. We report the outcomes of patients treated with preoperative RT, resection, and flap reconstruction. Patients and methods 122 treatment episodes involving 117 patients were retrospectively reviewed. All patients were treated with 50.4 Gy of external beam radiation. Surgery was performed at 4–8 weeks after completion of RT by the same combination of orthopedic oncology and plastic reconstructive surgeon. Defects were reconstructed with 64 free and 59 pedicled/local flaps. Results 30 (25%) patients experienced a MWC and 17 (14%) required further surgery. 20% of complications were exclusively related to the donor site. There was complete or partial loss of three flaps. There was no difference in the rate of MWC or reoperation for complications with respect to age, sex, tumor site, previous unplanned excision, tumor grade, depth, and type of flap. Tumor size ≥8 cm was associated with a higher rate of reoperation (11/44 vs 6/78; P = 0.008) but the rate of MWC was not significant (16/44 vs 14/78; P = 0.066). Conclusion The use of soft tissue flaps is associated with a low rate of MWC and reoperation. Our results suggest that a high rate of flap usage may be required to observe a reduction in complication rates.
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Affiliation(s)
- Lester Wai Mon Chan
- Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia.,Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jungo Imanishi
- Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia
| | | | - Peter Choong
- Department of Orthopaedics, St. Vincent's Hospital, Melbourne, VIC, Australia.,Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
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Abouarab MH, Salem IL, Degheidy MM, Henn D, Hirche C, Eweida A, Uhl M, Kneser U, Kremer T. Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy. Int Wound J 2017; 15:148-158. [PMID: 29205902 DOI: 10.1111/iwj.12851] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 10/11/2017] [Indexed: 01/31/2023] Open
Abstract
Soft tissue sarcomas occur most commonly in the lower and upper extremities. The standard treatment is limb salvage surgery combined with radiotherapy. Postoperative radiotherapy is associated with wound complications. This systematic review aims to summarise the available evidence and review the literature of the last 10 years regarding postoperative wound complications in patients who had limb salvage surgical excision followed by direct closure vs flap coverage together with postoperative radiotherapy and to define the optimal timeframe for adjuvant radiotherapy after soft tissue sarcomas resection and flap reconstruction. A literature search was performed using PubMed. The following keywords were searched: limb salvage, limb-sparing, flaps, radiation therapy, radiation, irradiation, adjuvant radiotherapy, postoperative radiotherapy, radiation effects, wound healing, surgical wound infection, surgical wound dehiscence, wound healing, soft tissue sarcoma and neoplasms. In total, 1045 papers were retrieved. Thirty-seven articles were finally selected after screening of abstracts and applying dates and language filters and inclusion and exclusion criteria. Plastic surgery provides a vast number of reconstructive flap procedures that are directly linked to decreasing wound complications, especially with the expectant postoperative radiotherapy. This adjuvant radiotherapy is better administered in the first 3-6 weeks after reconstruction to allow timely wound healing and avoid local recurrence.
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Affiliation(s)
- Mohamed H Abouarab
- Department of Plastic and Reconstructive Surgery and Burns, Faculty of Medicine, University of Alexandria, Alexandria, Egypt.,Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Iman L Salem
- Department of Plastic and Reconstructive Surgery and Burns, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Magdy M Degheidy
- Department of Plastic and Reconstructive Surgery and Burns, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Dominic Henn
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Ahmad Eweida
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany.,Head, Neck and Endocrine Surgery Unit, Department of Surgery, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Matthias Uhl
- Department of Radiation Oncology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Thomas Kremer
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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8
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Ho AL, Lyonel Carre A, Patel KM. Oncologic reconstruction: General principles and techniques. J Surg Oncol 2016; 113:852-64. [PMID: 26939879 DOI: 10.1002/jso.24206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 02/06/2023]
Abstract
Halsted's principle of radical mastectomy influenced cancer treatment for decades. Randomized controlled trials resulted in a paradigm shift to less radical surgery and the use of adjuvant therapies. Oncologic reconstruction performed by plastic surgeons has evolved, ranging from skin grafts and local flaps for smaller defects to pedicled flaps and free flaps for larger and more complex defects. Immediate reconstruction facilitates resection is oncologically safe and contributes to meaningful improvements in quality of life. J. Surg. Oncol. 2016;113:852-864. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Adelyn L Ho
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Antoine Lyonel Carre
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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López JF, Hietanen KE, Kaartinen IS, Kääriäinen MT, Pakarinen TK, Laitinen M, Kuokkanen H. Primary flap reconstruction of tissue defects after sarcoma surgery enables curative treatment with acceptable functional results: a 7-year review. BMC Surg 2015; 15:71. [PMID: 26055763 PMCID: PMC4460917 DOI: 10.1186/s12893-015-0060-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 05/29/2015] [Indexed: 12/31/2022] Open
Abstract
Background Sarcomas, a heterogeneous group of tumors, are challenging to treat and require multidisciplinary cooperation and planning. We analyzed the efficacy of flap reconstruction in patients with bone and soft tissue sarcoma. Methods Patient charts and operative records were retrospectively reviewed from January 2006 through October 2013 to identify sarcoma patient characteristics, postoperative complications, revisions, recurrences, and survival. Pedicled and/or free flap reconstruction was performed in 109 patients. Flap selection was based on defect size, and exposure of anatomically critical structures or major orthopedic implants. Results Of 109 patients, 71 (65.1 %) were men, and mean age was 56.4 years. Tumors most frequently located in a lower extremity (38.7 %). Primary sarcomas comprised 79.2 % and recurrences occurred in 18.9 %. Wide resection was performed for 65.7 %, and there were 10 planned amputations combined with flap reconstruction. A total of 111 tumors received 128 flaps: 76 pedicled flaps, 42 free flaps, and 5 combined (10 total) pedicled + free-flaps. The success rate was 94 % for the pedicled flap group, 97 % for the free-flap group, and 100 % for the pedicle + free-flap group. Of 35 patients, 5 developed deep prosthetic infections. Only one amputation due to disease progression was performed. Satisfactory functional outcome was achieved in 69 %. Survival rate during a mean (standard deviation) 3(2) year follow-up was 83.5 %. Conclusions Primary flap reconstruction after sarcoma surgery satisfies oncologic goals. Large tumors in difficult areas can be removed and complete tumor resection achieved. Our findings indicate a high survival rate after sarcoma surgery utilizing flap reconstruction and a low recurrence rate.
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Affiliation(s)
- Jenny Fabiola López
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland.
| | - Kristiina Elisa Hietanen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
| | - Ilkka Santeri Kaartinen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
| | - Minna Tellervo Kääriäinen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
| | - Toni-Karri Pakarinen
- Department of Orthopedics and Trauma, Unit of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Minna Laitinen
- Department of Orthopedics and Trauma, Unit of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Hannu Kuokkanen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
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Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery. Hand (N Y) 2014; 9:196-204. [PMID: 24839421 PMCID: PMC4022960 DOI: 10.1007/s11552-013-9567-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The purpose of this study is to investigate functional outcomes and cost impacts of immediate functional reconstruction performed in conjunction with limb-sparing resection of upper extremity soft tissue sarcomas. METHODS Patients undergoing simultaneous limb-sparing upper extremity soft tissue sarcoma resection and functional reconstruction between December 1998 and March 2004 were retrospectively identified, their medical records reviewed, and costs of surgery analyzed. Functional outcomes and patient satisfaction were assessed via patient surveys and the Toronto Extremity Salvage Score (TESS). RESULTS Thirteen patients met the inclusion criteria. Average follow-up was 43.3 months. Reconstructions included rotational innervated muscle flaps (n = 6), free innervated myocutaneous flaps (n = 1), and tendon transfers or grafts (n = 6). Overall survival was 85 % (n = 11) and disease-free survival was 77 % (n = 10). Average total cost of surgery was $26,655. Patients undergoing reconstruction for hand and forearm sarcomas had significantly higher total costs of surgery than those undergoing reconstruction for elbow and upper arm sarcomas. Survey response rate was 91 % (n = 10). Average TESS score was 76. Of the patients who worked preoperatively, 88 % returned to work postoperatively, and all patients who returned to work currently use their affected limb at work. CONCLUSIONS Patients undergoing immediate functional reconstruction for upper extremity soft tissue sarcoma resection achieved very good to excellent functional outcomes with quick recovery times and a high return-to-work rate following immediate functional reconstruction, thereby minimizing surgical cost impacts. Immediate functional reconstruction in the same surgical setting is thus a viable strategy following upper extremity soft tissue sarcoma resection.
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11
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Functional neuro-vascularized muscle transfer for oncological reconstruction of extremity sarcoma. Surg Oncol 2012; 21:263-8. [PMID: 22835825 DOI: 10.1016/j.suronc.2012.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 06/05/2012] [Accepted: 06/23/2012] [Indexed: 11/23/2022]
Abstract
The strategy of limb salvage following surgical resection of skeletal tumor has led to an increased demand for more complex reconstructive options in order to achieve better functional outcomes. Functional neuro-vascularized muscle transfer (FMT) is a beneficial tool for restoring joint movement involving the reconstruction of "movement" in the affected extremity. Until now, however, the clinical application of FMT was mainly limited to trauma cases and to date, very few studies have focused on musculoskeletal oncology. In this study, we reviewed patients who underwent wide resection for extremity sarcoma and functional reconstruction using FMT and discussed the advantages, indications and complications of the procedure.
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Penna V, Iblher N, Momeni A, Stark GB, Bannasch H. Free tissue transfer in reconstruction following soft tissue sarcoma resection. Microsurgery 2011; 31:434-40. [DOI: 10.1002/micr.20895] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 02/01/2011] [Indexed: 11/10/2022]
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13
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Saito A, Sawaizumi M, Imai T, Matsumoto S. Reconstruction following resection of soft-tissue sarcomas at the ankle region in seven patients. J Plast Reconstr Aesthet Surg 2010; 63:1712-6. [DOI: 10.1016/j.bjps.2009.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 09/23/2009] [Accepted: 09/25/2009] [Indexed: 11/28/2022]
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14
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Selection of Myocutaneous Flaps for Reconstruction Following Oncologic Resection of Sarcoma. Ann Plast Surg 2010; 64:307-10. [DOI: 10.1097/sap.0b013e3181b0260e] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Geller DS, Hornicek FJ, Mankin HJ, Raskin KA. Soft tissue sarcoma resection volume associated with wound-healing complications. Clin Orthop Relat Res 2007; 459:182-5. [PMID: 17452922 DOI: 10.1097/blo.0b013e3180514c50] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Limb-salvage surgery has become the standard of care for most soft tissue sarcomas. While primary closure is often possible, it is frequently complicated by wound-healing complications in the setting of previously irradiated tissue and surgical wounds closed under tension. We sought to identify a relationship between the volume of resected soft tissue and the rate of wound-healing complications. We retrospectively reviewed 108 patients who were treated over a 17-month period for soft-tissue sarcomas using limb-salvage methods. Of these, 87 patients were treated with primary wound closure and 21 patients underwent primary muscle flap closure at the time of wide surgical excision. Of the 87 patients treated with primary wound closure, the mean volume of resected tissue in the group with wound-healing complications was greater than that the group that healed without complications. The mean volume of resected tissue in the group with wound-healing complications was 919 cm3 +/- 1173 cm3 and the mean volume of resected tissue in the group without wound-healing complications was 456 cm3 +/- 704 cm3. Mean volume of resected tissue in the group of patients treated with primary flap coverage was 1908 cm3, over twice as large as the mean volume of resected tissue in the group of patients treated with primary closure.
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Affiliation(s)
- David S Geller
- Orthopaedic Oncology Service, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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Werier J, Ferguson P, Bell R, Hill R, Wunder J, O'Sullivan B, Kandel R. Model of radiation-impaired healing of a deep excisional wound. Wound Repair Regen 2006; 14:498-505. [PMID: 16939580 DOI: 10.1111/j.1743-6109.2006.00145.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite many well-recognized benefits, administration of ionizing radiation before surgical resection of malignancies is associated with a high risk of wound-healing complications. Most animal models investigating techniques to improve wound healing use a superficial wound. The goal of this study was to develop a novel model of radiation-impaired healing using a deep excisional wound, which is closer to the clinical situation. In the first part of this study, female Lewis rats were exposed to 0, 12, 15, or 18 Gy single-fraction radiation to the buttocks. Three weeks later, deep wounds were created by excision of the gluteus maximus muscle. Irradiated wounds had a lower rate of healing of the surgically created defect than unirradiated wounds (p<0.001), but there was no significant difference between the different doses of radiation. Impaired healing was still evident at 12 weeks. The second part of this study investigated the ability of porcine small-intestinal submucosa (SIS) to improve healing in this animal model. At 6 weeks, wounds implanted with SIS showed improved healing at all doses of radiation compared with unimplanted irradiated wounds. However, higher doses of radiation were still associated with a lower rate of healing. SIS induced a cellular response that was not evident in defects that did not receive SIS, suggesting that SIS has the potential to stimulate repair. This reproducible model of radiation-impaired wound healing closely resembles the clinical setting. The results indicate that this model can be used to investigate new biomaterials as possible therapeutic agents to enhance wound healing.
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Affiliation(s)
- Joel Werier
- Department of Orthopaedic Surgery, University of Ottawa, Canada
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Kim JY, Youssef A, Subramanian V, Rogers BA, Pollock RE, Robb GL, Chang DW. Upper Extremity Reconstruction Following Resection of Soft Tissue Sarcomas: A Functional Outcomes Analysis. Ann Surg Oncol 2004; 11:921-7. [PMID: 15466352 DOI: 10.1245/aso.2004.06.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Treatment for soft tissue sarcoma of the upper extremity has evolved to include limb salvage techniques. We reviewed our experience with limb salvage therapy for upper extremity sarcomas with an emphasis on functional outcomes following the reconstructive surgery. METHODS A retrospective analysis was performed of 81 consecutive patients with soft tissue sarcoma of the upper extremity who had limb salvage therapy with reconstruction by a plastic surgeon. Univariate and multivariate regression analyses of relevant outcome variables were performed. Enneking functional scores were obtained from 43 patients. RESULTS The study included 16 microvascular reconstructions and 67 non-microvascular reconstructions for a total of 83 reconstructions in 81 patients. The mean defect size was 129 cm(2) (standard deviation: 106 cm(2)). The mean total functional score was 23.1 (range, 9 to 30). Any reconstruction-related complication and preoperative chemotherapy use were associated with a 7.3 point (P = .03) and 4.7 point (P = .01) decrease in total functional score, respectively. Kaplan-Meier product-limit analysis showed 82% 5-year overall survival and 67% 5-year disease-free survival rates. CONCLUSIONS For soft tissue sarcoma of the upper extremity, limb salvage with good functional outcome is possible with a judicious approach to reconstruction.
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Affiliation(s)
- John Y Kim
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, TX 77030, USA
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