Limb salvage in malignant tumors

Surgical Outcomes and Complications of Custom-Made Prostheses in Upper Limb Oncological Reconstruction: A Systematic Review

Bone tumors of the upper limb are a common cause of bone pain and pathological fractures in both old and young populations. Surgical reconstruction and limb salvage have become valid options for these patients despite this kind of surgery being challenging due to the need for wide bone resection and the involvement of surrounding soft tissues. Computer-assisted technology helps the surgeon in pre-operative planning and in designing customized implants. The aim of this study was to investigate the surgical outcomes and complications of custom-made prostheses in oncologic reconstruction of the upper limb and if they are reliable options for patients suffering from aggressive tumors. An electronic search on PubMed, Google Scholar, and Web of Knowledge was conducted to identify all available articles on the use of custom-made prostheses in oncological resections of the upper limb. Twenty-one studies were included in the review, comprising a total of 145 patients with a mean age of 33.68 years. The bone involved was the humerus in 93 patients, and the radius was involved in 36 patients. There were only six cases involving proximal ulna, three cases involving the scapula, and seven cases involving the elbow as well as soft tissues around it. The most frequent primary tumor was the giant cell tumor, with 36 cases, followed by osteosarcoma with 25 cases, Ewing Sarcoma with 17 cases, and Chondrosarcoma with 7 total cases. Forty patients were affected by bone metastases (such as renal cell cancer, breast cancer, melanoma, and rectal cancer) or hematologic diseases involving bone (lymphoma, myeloma, or non-Hodgkin disease). Custom-made prostheses are a viable option for patients who suffer from malignant tumors in their upper limbs. They are a reliable aid for surgeons in cases of extensive resections.

Extremity and Truncal Soft Tissue Sarcoma: Risk Assessment and Multidisciplinary Management

Extremity and truncal soft tissue sarcomas are a heterogeneous group of rare cancers that arise from mesenchymal tissues. Hence, the adoption of tailored risk assessment and prognostication tools plays a crucial role in optimizing the decision-making for which of the many possible treatment strategies to select. Management of these tumors requires a multidisciplinary strategy, which has seen significant development in recent decades. Surgery has emerged as the primary treatment approach, with the main goal of achieving microscopic negative tumor margins. To reduce the likelihood of local recurrence, loco-regional treatments such as radiation therapy and isolated limb perfusion are often added to the treatment regimen in combination with surgery. This approach also enables surgeons to perform limb-sparing surgery, particularly in cases where a positive tumor margin is expected. Chemotherapy may also provide a further benefit in decreasing the probability of local recurrence or reducing distant metastasis in selected patients. Selecting the optimal treatment strategy for these rare tumors is best accomplished by an experienced multi-disciplinary team.

Do the Histological Differences of Soft Tissue Sarcomas Affect the Rate of Skin Defect Reconstruction?

BACKGROUND

In soft tissue sarcoma (STS) resection, flap reconstruction and/or skin grafting is frequently required. However, it is not clear whether the histological difference affects the rate of reconstruction. The present study aimed to investigate it.

METHODS

This study compared in 5 classifications (105 adipocytic tumors, 102 fibroblastic tumors, 39 muscle tumors, 31 peripheral nerve sheath tumors, and 178 tumors of uncertain differentiation). In addition, the reconstruction rates of detailed tumor sites were compared. The median and case number (percentage) were calculated.

RESULTS

Tumor size (adipocytic 112 mm vs fibroblastic 79 mm, muscle 72 mm, nerve 90 mm, uncertain 74 mm, P < 0.0001 in all comparisons), histological low-grade rates (adipocytic 43.8% vs uncertain 3.9%, P < 0.0001; fibroblastic 46.1% vs muscle 15.4%, P = 0.003; fibroblastic vs uncertain, P < 0.0001; nerve 19.4% vs uncertain, P = 0.003) and reconstruction rates (adipocytic 5.7% vs fibroblastic 42.2%, muscle 33.3%, nerve 32.3%, uncertain 25.8%, P < 0.0001 in all comparisons) were significantly different. In the region of lower extremity, the regions of thigh [adipocytic 1/62 (1.6%) vs fibroblastic 7/32 (21.9%), P = 0.002], and lower leg [adipocytic 1/16 (6.3%) vs fibroblastic 11/19 (57.9%), P = 0.002] were significantly different.

CONCLUSIONS

In adipocytic tumors, the tumor size was significantly large; however, the skin defect reconstruction rate was significantly lower than that of the other STS. Histologically, the reconstruction rate of STS derived from superficial tissue increases, whereas the reconstruction rate derived from deep tissue such as adipocytic tumor decreases.

Free Fillet Flap of Lower Extremity: 38 Amputations with Seven Examples of Targeted Muscle Reinnervation and Regenerative Peripheral Nerve Interfaces

BACKGROUND

Extremely high-level lower extremity amputations are rare procedures that require significant soft-tissue and bony reconstruction. This study describes the use of fillet flaps for oncologic reconstruction and the incorporation of targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNIs) for chronic pain prevention.

METHODS

The authors performed a retrospective review of patients who underwent lower extremity fillet flaps at MD Anderson Cancer Center from January of 2004 through April of 2021. Surgical outcomes were summarized and compared. Numeric rating scale and patient-reported outcomes measures were collected.

RESULTS

Thirty-eight fillet flaps were performed for lower extremity reconstruction. Extirpative surgery included external hemipelvectomy (42%), external hemipelvectomy with sacrectomy (32%), and supratrochanteric above-knee amputation (26%). Median defect size was 600 cm 2 , and 50% included a bony component. Twenty-one patients (55%) experienced postoperative complications, with 16 requiring operative intervention. There was an increased trend toward complications in patients with preoperative radiotherapy, although this was not significant (44% versus 65%; P = 0.203). Seven patients underwent TMR or RPNI. In these patients, the mean numeric rating scale residual limb pain score was 2.8 ± 3.4 ( n = 5; range, 0 to 4/10) and phantom limb pain was 4 ± 3.2 ( n = 6; range, 0 to 7/10). The mean Patient-Reported Outcomes Measures Information Systems T scores were as follows: pain intensity, 50.8 ± 10.6 ( n = 6; range, 30.7 to 60.5); pain interference, 59.2 ± 12.1 ( n = 5; range, 40.7 to 70.1); and pain behavior, 62.3 ± 6.7 ( n = 3; range, 54.6 to 67.2).

CONCLUSIONS

Lower limb fillet flaps are reliable sources of bone, soft tissue, and nerve for reconstruction of oncologic amputation. TMR or RPNI are important new treatment adjuncts that should be considered during every amputation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcomes of plastic surgical reconstruction in extremity and truncal soft tissue sarcoma: Results from the US Sarcoma Collaborative

BACKGROUND

This study aimed to define how utilization of plastic surgical reconstruction (PSR) affects perioperative outcomes, locoregional recurrence-free survival (LRRFS), and overall survival (OS) after radical resection of extremity and truncal soft tissue sarcoma (ETSTS). The secondary aim was to determine factors associated with PSR.

METHODS

Patients who underwent resection of ETSTS between 2000 and 2016 were identified from a multi-institutional database. PSR was defined as complex primary closure requiring a plastic surgeon, skin graft, or tissue-flap reconstruction. Outcomes included PSR utilization, postoperative complications, LRRFS, and OS.

RESULTS

Of 2750 distinct operations, 1060 (38.55%) involved PSR. Tissue-flaps (854, 80.57%) were most commonly utilized. PSR was associated with a higher proportion of R0 resections (83.38% vs. 74.42%, p < 0.001). Tissue-flap PSR was associated with local wound complications (odds ratio: 1.81, confidence interval: 1.21-2.72, p = 0.004). Neither PSR nor postoperative complications were independently associated with LRRFS or OS. High-grade tumors (1.60, 1.13-2.26, p = 0.008) and neoadjuvant radiation (1.66, 1.20-2.30, p = 0.002) were associated with the need for PSR.

CONCLUSION

Patients with ETSTS undergoing resection with PSR experienced acceptable rates of complications and a higher rate of negative margins, which were associated with improved LRRFS and OS. High tumor grade and neoadjuvant radiation were associated with requirement of PSR.

Contemporary role of amputation for patients with extremity soft tissue sarcoma

INTRODUCTION

limb-sparing surgery is the mainstream treatment for primary extremity soft tissue sarcoma (ESTS) at referral centers, following advances in surgical reconstructions and multimodal management. However, amputation is still needed in selected patients and has not yet been described for a ESTS cohort in a contemporary scenario.

MATERIAL AND METHODS

consecutive patients who underwent surgery for primary ESTS from 2006 to 2018 were extracted from a prospectively collected database at our reference center. Patients receiving amputation for either primary tumor or local recurrence (LR) after limb-sparing surgery were selected for analysis.

RESULTS

Among 1628 primary ESTS, 29 patients underwent primary amputation (1.8%), 22/1159 (1.9%) for upper limb and 7/469 (1.5%) for lower limb ESTS. Patients were mainly affected by grade III FNCLCC (89.6%) of notable dimension (median size 16 cm, IQR 10-24). 65.5% of patients received preoperative treatments (systemic or regional chemotherapy, radiotherapy or chemo-radiation). Secondary amputation for LR was performed after a median of 23 months in 16/1599 patients (1%). Median survival time was 16.2 and 29.6 months after primary or secondary amputation respectively. Factors prompting the need for a primary amputation were most often a combination of multifocal disease, bone invasion and pain or neurovascular bundle involvement and relevant comorbidities, mainly for grade III tumors in elderly patients.

CONCLUSION

Contemporary rate of amputation for ESTS at a reference center is extremely low. Still, amputation is required in selected cases with advanced presentations, especially in elderly, frail patients.

The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany-Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa)

Simple Summary

The mainstay of soft-tissue-sarcoma treatment remains ablative surgery with complete tumor resection. In this context, reconstructive plastic surgery has become an important aspect of multidisciplinary sarcoma therapy aiming at limb preservation as an alternative to amputations. In this present study, cross-sectional data collected prospectively at 39 study centers across Germany were analyzed, focusing on both the inhouse availability of plastic surgery and external accessibility to plastic surgery in 621 cases. In summary, unplanned and incomplete primary tumor resections carried out at centers with lower degrees of specialization were associated with a significantly increased need for subsequent flap-based defect coverage. In line with this, a readily available team of plastic surgeons was independently associated with successful defect reconstruction, which in turn was associated with significantly higher chances of limb preservation. We conclude that easily accessible plastic surgery and a high degree of expertise in the field of sarcoma treatment are indispensable for limb preservation following sarcoma resection. Plastic and reconstructive surgery therefore plays a vital role in achieving the best possible outcomes in the interdisciplinary treatment of soft-tissue sarcomas.

Abstract

Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.

Non-oncological outcomes following limb salvage surgery in patients with knee sarcoma: a scoping review

Purpose: Limb salvage surgery is a surgical procedure for tumour resection in bone and soft-tissue cancers. Guidelines aim to preserve as much function and tissue of the limb as possible. Surgical outcome data is routinely available as part of surgical reporting processes. What is less known are important non-oncological outcomes throughout recovery from both clinical and patient perspectives. The objective of this review was to explore non-oncological outcomes in patients diagnosed with sarcoma around the knee following limb salvage surgery. Materials and Methods: A scoping review methodology was used, and results analysed using CASP checklists. Results: Thirteen studies were included and following appraisal and synthesis, three themes emerged as providing important measures intrinsic to successful patient recovery: (1) physical function, (2) quality of life and, (3) gait and knee goniometry. Specifically, patients develop range of motion complications that alter gait patterns and patients often limit their post-operative participation in sport and leisure activities. Conclusions: This study has shown the importance of exploring confounding factors, adopting a holistic view of patient recovery beyond surgical outcomes, proposing evidence-based guidance to support and inform healthcare providers with clinical decision-making. This review highlights the paucity and lack of quality of research available, emphasising how under-represented this population is in the research literature.IMPLICATIONS FOR REHABILITATIONPatients having undergone LSS often have limited participation in sport and leisure activities.Patients can develop range of motion complications, such as flexion contracture or extension lag, which may affect the pattern of gait.Clinical consideration should be given to walking ability and gait patterns during the rehabilitation phase to prevent poor functional outcomes during recovery.Variation of treatment protocols, outcome measurement and rehabilitative care has been identified as important in predicting the outcomes in recovery from LSS procedures.

Microvascular tissue transfer after the resection of soft tissue sarcomas

BACKGROUND

Microvascular tissue transfer enables the oncological resection of soft tissue sarcomas of the extremities and the trunk by covering the resulting tissue defects that are often extensive. This study was performed to investigate the long-term survival and functional outcome of patients treated with free flaps after sarcoma resection.

METHODS

A total of 78 sarcoma patients received microvascular tissue transfer in our institution between March 2003 and January 2013. In a retrospective analysis, we investigated data such as tumor characteristics as well as survival time and disease-free survival. In a prospective analysis, we assessed the functional outcome and the health-associated quality of life with the TESS and SF-36 questionnaire, respectively.

RESULTS

Seventy patients qualified for disease-free survival after tumor resection, 41 patients remained disease free for over 5 years. Forty-five patients reached a survival time of more than 5 years. The functional results experienced by our patients were good with a mean score of 82.6% in the TESS. The physical health-related quality was lower than in the German norm sample and patients suffering from chronical illnesses or cancer, whereas the mental health was only slightly lower than in the norm sample and higher than in the groups with chronic illnesses or cancer (SF-36).

CONCLUSION

Microvascular tissue transfer enables tumor resection and limb salvage through the coverage of the resulting defects without impairing patients' prognosis. The long survival times after tumor resection emphasizes the need for good functional results as well as quality of life.

The Microsurgical Calcaneus Osteocutaneous Fillet Flap After Traumatic Amputation in Lower Extremities: Flap Design and Harvest Technique

BACKGROUND

Attempts to salvage upper and lower extremities have performed more frequently in recent decades, although there are clear cases that cannot be salvaged. The purpose of this retrospective study was to present our experience in using free calcaneus osteocutaneous fillet flap for preserving below-knee amputation stump after traumatic amputations or functional preserving after nonsalvageable lower extremities.

METHODS

Between January 2012 and May 2017, 11 free calcaneus osteocutaneous fillet flap were used to preserving or lengthening below-knee amputation stump secondary to amputation on 8 males and 3 females. Patients' information and postoperative data were collected, including age of patient, sex, amputation site, flap survival, sensation recovery, and number of complications.

RESULT

All amputations were trauma related and secondary to motor vehicle accidents (n = 8) and industrial accidents (n = 3). The age of the patients ranged from 16 to 59 years, with a mean of 34.4 years. Free calcaneus osteocutaneous fillet flap were designed and harvested from all patients. All flaps survived and 2 complications developed in 2 patients. Nine of 11 patients obtained protective sensory recovery during the period of follow-up.

CONCLUSIONS

The free calcaneus osteocutaneous fillet flap harvested from the amputated limb provides reliable and robust tissue for reconstruction of large defects of the residual limb without additional donor-site morbidity.

Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy

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.

Minimally invasive surgery using intraoperative electron-beam radiotherapy for the treatment of soft tissue sarcoma of the extremities with tendon involvement

Background

When a soft tissue sarcoma (STS) is located at the distal part of an extremity and involves the tendon, a wide excision usually causes severe functional disability. We therefore developed a minimally invasive surgical technique using intraoperative electron-beam radiotherapy (IOERT) to reduce the incidence of post-operative functional disability in patients with peri-/intra-tendinous STS. We assessed the clinical outcomes of the novel minimally invasive surgery.

Methods

The study population included five patients who received treatment for distal extremity STSs. After elevating the tumor mass, including the tendon and nerve from the tumor bed with a wide margin, a lead board was inserted beneath the tumor mass to shield the normal tissue. IOERT (25–50 Gy) was then applied, and the tumor excised with care taken to maintain the continuity of the tendon.

Results

In a desmoid patient, local recurrence was observed outside the irradiated field. No cases of neuropathy or bone necrosis were observed. The mean limb function score was excellent in all patients. None of the high-grade sarcoma patients had local recurrence or distant metastasis.

Conclusions

Although the current study is only a pilot study with a small number of patients, it shows that this minimally invasive procedure has the potential to become a standard treatment option for selected patients.

Trial registration

H17-250 (registered 2 November 2005) and H25-250 (modified from H17-250, registered 5 December 2013)

Reconstruction of Soft-Tissue Defects at the Foot and Ankle after Oncological Resection

Introduction

Solid malignancies at the foot and ankle region are rare and include mainly soft-tissue sarcomas, bone sarcomas, and skin malignancies. Complete surgical resection with clear margins still remains the mainstay of therapy in these malignancies. However, attainment of negative surgical margins in patients with locally advanced tumors of the foot and ankle region may require extensive surgery and could result in loss of extremity function. In these circumstances, plastic surgical techniques can frequently reduce functional impairment and cover soft-tissue defects, particularly in cases of large tumor size or localization adjacent to critical anatomic structures, thereby improving the quality of life for these patients. The aim of this article is to illustrate the various treatment options of plastic surgery in the multimodal therapy of patients with malignant tumors of the foot and ankle region.

Materials and methods

This article is based on the review of the current literature and the evaluation of the author’s own patient database.

Results

The local treatment of malignant extremity tumors has undergone major changes over the last few decades. Primary amputations have been increasingly replaced by limb-sparing techniques, preserving extremity function as much as possible. Although defect coverage at the foot and ankle region is demanding due to complex anatomical features and functional requirements, several plastic surgical treatment options can be implemented in the curative treatment of patients with malignant solid tumors in this area. Soft-tissue defects after tumor resection can be covered by a variety of local flaps. If local flaps are not applicable, free flap transfers, such as the anterolateral thigh flap, parascapular flap, or latissimus dorsi flap, can be utilized to cover nearly all kinds of defects in the foot and ankle region.

Conclusion

Soft-tissue reconstruction in the foot and ankle region is a vital component of limb-sparing surgery. It enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. Modern plastic surgical techniques should, therefore, be integrated in the multimodal treatment concept of malignancies in the foot and ankle region.

Epiphyseal Sparing and Reconstruction by Frozen Bone Autograft after Malignant Bone Tumor Resection in Children

Limb salvage surgery has become the standard treatment for malignant primary bone tumors in the extremities. Limb salvage represents a challenge in skeletally immature patients. Several treatment options are available for limb reconstruction after tumor resection in children. We report our results using the technique of epiphyseal sparing and reconstruction with frozen autograft bone in 18 children. The mean follow-up period for the all patients included in this study is 72 ± 26 m. Eight patients remained disease-free, seven patients lived with no evidence of disease, two were alive but with disease, and one patient died of the disease. Five- and ten-year rates of survival were 94.4%. Graft survival at 5 and 10 years was 94.4%. Functional outcome using the Enneking scale was excellent in 17 patients (94.4%) and poor in one patient (5.5%). Complications include 2 nonunions, 2 fractures, 2 deep infections, 1 soft tissue recurrence, and leg length discrepancy in 7 cases. This technique is a good reconstructive choice in a child with a nonosteolytic primary or secondary bone tumor, responsive to chemotherapy, without involvement of the articular cartilage. It is a straight forward, effective, and biological technique, which affords immediate mobilization of joints and possible cryoimmune effects, with excellent long term functional outcome and less complication.

The long-term outcomes following the use of inactivated autograft in the treatment of primary malignant musculoskeletal tumor

Background

Biological reconstruction surgery is a tough but alluring option for treating primary malignant musculoskeletal tumors. In this article, we evaluate the clinical outcomes of primary malignant musculoskeletal tumors treated with inactivated autograft using alcohol.

Method

In this article, we include 58 patients who had primary malignant bone tumors treated with wide resection and recycling autograft reconstruction using alcohol between January 2003 and January 2013. The outcomes were measured by recurrence, functional status, and complications. Functional status was assessed according to the Musculoskeletal Tumor Society Score (MSTSS). The Kaplan-Meier survival curve was used to evaluate the survival rate of the patient.

Result

The most common tumor was osteosarcoma (31 cases) followed by chondrosarcoma (10 cases). The tibia was the most frequently involved skeletal site (27 cases) followed by femur (26 cases). The median follow-up period was 54 months, ranging from 18 to 96 months. In 58 patients, 12 were with local recurrence (20.7 %), 16 with lung metastasis (27.6 %), and 13 with complications (22.4 %). The main complication was infection (8 cases). The autografts survived in 49 patients (84.5 %). The mean MSTSS score was 78.5 %, ranging from 47 to 98 %.

Conclusion

Recycling autograft reconstruction using alcohol had favorable clinical outcomes to some degree; however, the recurrence and complication rates seem to be high. Thus, we should apply this method with caution and choose the patients with strict surgical indication.

Primary flap reconstruction of tissue defects after sarcoma surgery enables curative treatment with acceptable functional results: a 7-year review

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.

Local tendon transfer for knee extensor mechanism reconstruction after soft tissue sarcoma resection

PURPOSE

Aim of this study was to measure the outcome of hamstring transfer for quadriceps reconstruction after soft tissue sarcoma resection and to identify risk factors influencing postoperative results.

METHODS

43 patients underwent hamstring transfer after sarcoma resection. Medical records were reviewed for surgical technique and complications. Physical examination included assessment of range of motion and muscle strength as well as plantar pressure distribution by computerized dynamometer and podometry, respectively. Additionally, patients' satisfaction, quality of life and karnofsky index were assessed.

RESULTS

Sole biceps transfer was performed in 31 (74%) and combined biceps/semitendinosus or gracilis transfer in 12 patients (26%). In 91%of cases 3/4 or more of the quadriceps muscle had to be removed. Postoperative complications occurred in 16 patients (37%). 17 patients (40%) were available for physical examination. Mean follow-up was 61 months (22-107). Average knee flexion was 74° (35-110°). All patients had full knee extension. Average extension force was 44% (19-79%) and flexion-force 74% (55-100%) of the unaffected leg. Mean plantar pressure distribution was 119% (44-200%) on the forefoot and 107% (60-169%) on the heel. Average patient satisfaction score was 16 (9-25), quality of life assessment was 78 (54-92) and Karnofsky Index was 82% (70-90%). Besides patient's age and the extent of resection, the surgical technique had statistically significant influence on functional outcome and postoperative complications (p < 0.05).

CONCLUSION

Hamstring transfer is feasible for quadriceps reconstruction after massive tumor resection from the thigh. In contrast to biceps alone, combined semitendinosus or gracilis transfer revealed comparable outcome but higher complication rates.

Plastic surgery for the oncological patient

The therapy of oncological patients has seen tremendous progress in the last decades. For most entities, it has been possible to improve the survival as well as the quality of life of the affected patients. To supply optimal cancer care, a multidisciplinary approach is vital. Together with oncologists, radiotherapists and other physicians, plastic surgeons can contribute to providing such care in all stages of treatment. From biopsies to the resection of advanced tumors, the coverage of the resulting defects and even palliative care, plastic surgery techniques can help to improve survival and quality of life as well as mitigate negative effects of radiation or the problems arising from exulcerating tumors in a palliative setting. This article aims to present the mentioned possibilities by illustrating selected cases and reviewing the literature. Especially in oncological patients, restoring their quality of life with the highest patient safety possible is of utmost importance.

The long-term outcome following the use of frozen autograft treated with liquid nitrogen in the management of bone and soft-tissue sarcomas

In 1999, we developed a technique for biological reconstruction after excision of a bone tumour, which involved using autografts of the bone containing the tumour treated with liquid nitrogen. We have previously reported the use of this technique in 28 patients at a mean follow up of 27 months (10 to 54).

In this study, we included 72 patients who underwent reconstruction using this technique. A total of 33 patients died and three were lost to follow-up, at a mean of 23 months (2 to 56) post-operatively, leaving 36 patients available for a assessment at a mean of 101 months 16 to 163) post-operatively. The methods of reconstruction included an osteo-articular graft in 16, an intercalary in 13 and, a composite graft with prosthesis in seven.

Post-operative function was excellent in 26 patients (72.2%), good in seven (19.4%), and fair in three (8.3%) according to the functional evaluation system of Enneking. No recurrent tumour occurred within the grafts. The autografts survived in 29 patients (80.6%), and the rates of survival at five and ten years were 86.1% and 80.6 %, respectively. Seven of 16 osteo-articular grafts (44%) failed because of fracture or infection, but all the composite and intercalary grafts survived.

The long-term outcomes of frozen autografting, particularly using composite and intercalary grafts, are satisfactory and thus represent a good method of treatment for patients with a sarcoma of bone or soft tissue.

Cite this article: Bone Joint J 2014;96-B:555–61.

[Long-term functional results after sarcoma resection]

Multimodal treatment of malignant tumors of the musculoskeletal system with R0 in sano resection plays a key role in prevention of local recurrence in soft tissue and bone sarcoma. In cases of unavoidable neuromuscular or osseous defects, current plastic and orthoplastic reconstruction techniques avoid limb amputation in the majority of patients. Clinical long-term results demonstrate that large resection defects do not necessarily result in impaired limb function if multidisciplinary procedures are integrated. In oncologically necessary major limb amputation, segmental resection and replantation of distal limb parts should be considered which provide end-bearing long stump formation. The functional conditions of long-term surviving elderly patients should be integrated into surgical decision-making and rehabilitation efforts.

[Soft tissue sarcoma : resection and plastic reconstruction]

Adequate surgical removal of soft tissue sarcomas of the trunk and extremities employing safety margins of 1-2 cm is the accepted basis of multidisciplinary treatment. In cases of high risk tumors (grades G2/G3) the tumor board decision should include radiochemotherapy under study conditions. Difficult peripheral locations or perioperative complications require additional techniques, such as hyperthermic perfusion with tumor necrosis factor alpha or the complete spectrum of reconstructive plastic procedures. Patients with soft tissue sarcoma of the trunk or of the extremities should always be referred to high volume centers.

Functional outcome of limb-salvage surgery with shoulder abduction brace for bone tumors around the shoulders

BACKGROUND

The current trend is toward salvage of the extremity after tumor excision without compromising the extent of resection for bone tumor around the shoulders.

OBJECTIVES

The aim of this study was to evaluate functional outcome of patients treated with limb-salvage surgeries combined with shoulder abduction braces.

METHODS

Thirty-six patients with bone tumors around the shoulders, who had limb-sparing resection and reconstruction performed with a shoulder abduction brace, were retrospectively reviewed. Allograft transplantation and rigid internal fixation was performed in 22 patients and artificial prosthetic replacement was performed in 14 patients. Functional evaluation was performed based on the Musculoskeletal Tumour Society (MSTS) scoring system.

RESULTS

The overall survival was 78.8% (26/33) at 2 years. The mean final functional score was (81.2 ± 19.6%). The MSTS of patients treated by allograft transplantation and prosthetic replacement were (79.4 ± 15.3%) and (81.9 ± 18.1%), respectively. The MSTS scores differed only slightly between these two groups (P > 0.05). All the patients regained good ROM of the shoulder joints.

CONCLUSIONS

Satisfactory functional outcomes can be obtained by limb-salvage surgery for bone tumor around the shoulder. Postoperatively shoulder crutches with shoulder abduction brace are encouraged as the aid of reconstruction of shoulder joint function.

Locking compression plate in musculoskeletal oncology 'a friend in need'

Background

We are presenting our experience in the use of locking compression plate (LCP) after juxta-articular oncological resections in addition to its use in pathologic fracture.

Methods

A retrospective audit of skeletal reconstruction using LCP in 25 cases of long bone tumors was performed from 2008 to 2010. Reconstruction following limb salvage surgery was done in 17 patients and internal fixation of pathological fracture was done in 8 patients. All patients were available for > 12 months of follow-up, and thus assessed for union at the resected ends.

Results

There were 8 males and 17 females in the study. The average age at the time of surgery was 30 years (range, 9 to 66 years). The minimum follow-up was 12 months (range, 12 to 32 months). All patients except three went on to heal successfully. Complications occurred in those three patients: wound infection in one, nonunion in another, and periprosthetic fracture in the other patient. In the remaining patients, union was achieved at an average of 6.5 months after reconstruction in curative resection and 4.75 months after fixation of pathological fractures.

Conclusions

Joint sparing limb salvage surgery was made successfully possible after sekeletal reconstruction with LCP. Its use was also quite effective in pathological fractures with poor bone quality. Use of locking plates for musculoskeletal oncological reconstruction resulted in a good and predictable rate of union.

CASE REPORT Rotational Vascularized Tibiaplasty After Oncologic Resection and Major Wound Healing Problems: A Novel Technique

OBJECTIVE

To describe a novel method to reconstruct, with a vascularized rotational tibiaplasty, a complex femoral defect in an adolescent.

METHODS

After a femoral osteosarcoma resection, allograft reconstruction, and chemotherapy, an 11-year-old girl developed recurrent thigh wound infections and femoral allograft osteomyelitis despite multiple operative interventions. At the age of 13, she presented to our center with a complex right thigh wound and an unstable lower extremity secondary to a segmental femoral loss. To reestablish thigh stability and function and to avoid amputation at the hip, the authors performed a rotational vascularized tibiaplasty. The tibia was rotated 180° with the pivot at the knee. The distal tibia was internally stabilized to the residual proximal femur.

RESULTS

Ten years later, the patient had a stable thigh, a functional hip, no evidence of infection or sarcoma, and a Toronto Extremity Salvage Score of 92.5 (minimal disability).

CONCLUSIONS

In this patient, the tibial rotationplasty provided a vascularized bone strut mimicking the resected femur; saved the hip; obviated an allograft bone; and created a functional, biologic, stable, and durable thigh that allowed full weight bearing on a prosthesis, with a low physical disability level. We conclude that, for patients with complex femoral defects, a vascularized rotational tibiaplasty should be considered a feasible option before amputation.

[Soft tissue sarcoma. Resection and plastic reconstruction]

Adequate surgical removal of soft tissue sarcomas of the trunk and extremities employing safety margins of 1-2 cm is the accepted basis of multidisciplinary treatment. In cases of high risk tumors (grades G2/G3) the tumor board decision should include radiochemotherapy under study conditions. Difficult peripheral locations or perioperative complications require additional techniques, such as hyperthermic perfusion with tumor necrosis factor alpha or the complete spectrum of reconstructive plastic procedures. Patients with soft tissue sarcoma of the trunk or of the extremities should always be referred to high volume centers.

[Current state of neoadjuvant therapy of soft tissue sarcoma]

The treatment of soft tissue sarcoma is clinically challenging. Referral to an experienced center with an interdisciplinary team is strongly recommended. Neoadjuvant therapy, including irradiation and chemotherapy, has been applied to improve local control rates, eradicate micrometastases and assess chemosensitivity. However, the role of neoadjuvant therapy remains controversial, especially for systemic therapy, as the only available randomized trial failed to prove a benefit for survival. Nevertheless, on the basis of the current body of literature, neoadjuvant therapy can be considered on an individual basis for patients with high-risk tumors. Whenever possible, patients should be included in a clinical trial.

Reconstructive treatment of soft tissue sarcoma of the upper extremity

Limb-sparing surgery is currently the cornerstone of treatment for most patients with soft-tissue sarcoma of the upper extremity. To achieve the best outcome, the reconstructive surgeon must be part of a multidisciplinary team and is required to have a thorough understanding of the whole treatment concept. This article provides an update for the current surgical management of patients with soft tissue sarcoma of the upper extremity. Relevant nonsurgical aspects are also highlighted.