Reconstruction of Massive Oncologic Defects Following Extremity Amputation: A 10-Year Experience

Practical Strategies in Reconstruction of Soft-Tissue Sarcoma

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Discuss the natural history and pathophysiology of sarcoma. 2. Summarize the most up-to-date multidisciplinary management of soft-tissue sarcoma. 3. Provide a synopsis of reconstructive modalities based on anatomical location. 4. Highlight some novel strategies for treatment of lymphedema and phantom limb pain that are common sequelae following treatment and resection of soft-tissue sarcomas.

SUMMARY

The management of soft-tissue sarcoma presents unique challenges to the reconstructive surgeon. The optimal management mandates a multidisciplinary approach; however, reconstruction must take into account the extent of the resection and exposed vital structures, but often occurs in the setting of adjuvant treatments including chemotherapy and radiation therapy. Reconstruction is based on the extent of the defect and the location of the primary tumor. As such, an evidence-based, algorithmic approach following the reconstructive ladder is warranted to minimize the risks of complications and maximize success, which varies from head and neck to torso to breast to extremity sarcomas. Aside from reconstruction of the defect, advances in the surgical treatment of lymphedema and neuropathic pain resulting from treatment and extirpation of soft-tissue sarcoma are critical to maintain function and patients' quality of life.

Multidisciplinary Approach to Hemipelvectomy for Pelvic Sarcomas

» Pelvic sarcomas are a rare and diverse group of tumors in terms of size and histology.» Pelvic sarcomas present a treatment challenge to the orthopaedic oncologist.» The size and location of these tumors require a varied approach to resection and reconstruction, but the tumor's proximity to other internal structures within the pelvis (e.g., the bladder, the iliac vessels, and the bowel) makes extrication demanding.» The ideal treatment requires assembling a hemipelvectomy team that consists of an orthopaedic oncologist, a surgical oncologist, a urologist, a vascular surgeon, a gynecologic oncologist, a plastic and reconstructive surgeon, a dedicated anesthesia team, and a dedicated rehabilitation physical therapy team. Each member can use his or her expertise to address the individual aspects of the pelvic resection and achieve the optimal oncologic and functional outcome.

Application of Spare Parts in Combination with Targeted Muscle Reinnervation Surgery

SUMMARY

Targeted muscle reinnervation is a contemporary technique designed to enhance an amputee's ability to operate a myoelectric prosthesis. This technique has been shown to decrease neuropathic pain, including neuroma and phantom limb pain. In certain amputations, especially forequarter and hindlimb levels, there may be no nearby recipient muscle sites, or the residual nerve may be too short to perform targeted muscle reinnervation. Applying the spare parts concept can help solve this problem by providing nerve autograft or additional muscle recipient sites within the spare parts flap for successful targeted muscle reinnervation surgery procedures. A retrospective review of all patients that underwent spare parts targeted muscle reinnervation reconstructions between 2016 and 2019 at two institutions was performed. Patients were assessed for healing, neuroma and phantom limb pain, and function. Twelve patients underwent targeted muscle reinnervation during spare parts reconstruction; eight were male and four were female. The mean patient age was 55.3 years (range, 16 to 72 years). For those with known soft-tissue deficit size, the surface area of the donor site spared by using spare parts reconstruction ranged from 216 to 856 cm2. None of the 12 patients subsequently experienced neuroma, and 75 percent had no phantom limb pain after 3 months. Three patients have obtained insurance-approved myoelectric prosthetics, and all three demonstrated intuitive control of targeted muscles. Using a spare parts reconstruction in conjunction with targeted muscle reinnervation may optimize reconstructive efforts in the setting of major limb amputations and aid in decreasing phantom limb and neuroma pain, and facilitate the possibility of functional prosthetic and/or myoelectric prosthesis use.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Soft tissue reconstruction after pelvic amputation: The efficacy and reliability of free fillet flap reconstruction

BACKGROUND

The majority of hindquarter amputation defects can be reconstructed with local anterior or posterior thigh flaps. Less than 5% of soft tissue defects require free flap reconstruction after tumour resection. Lower extremity fillet flap is described for reconstructing such defects, but the majority of publications are case reports or short single institutional series. There is a lack of data regarding the oncological outcomes of this highly selected patient group.

METHODS

Three tertiary sarcoma units treated twelve patients with hindquarter amputation or hip disarticulation for oncological indications with a free flap reconstruction of the soft tissue defect.

RESULTS

The median age of patients was 60 (range 12-76) years. Bone resection was carried out through the SI-joint in six patients and through the sacrum in five patients, with one patient undergoing hip disarticulation. Nine patients had R0 resection margin and three had R1 resection. The median surgical time and flap ischaemia time was 420 (249-650) and 89 (64-210) min, respectively. Median hospital and ICU stay was 18 (10-42) and 3 (1-8) days, respectively. Median blood loss was 2400 (950-10000) ml. There were three returns to theatre due to vascular compromise, with one total flap loss due to arterial thrombosis. Overall survival was 58% (95%CI 28-91%) both at 1-year and at 3-years.

DISCUSSION

Carefully selected patients requiring hindquarter amputation with extensive soft tissue defect necessitating free flap reconstruction can be reconstructed with a lower extremity free fillet flap with low rate of local wound complications. Survival of these patients is similar to that in patients requiring less extensive resection.

Forequarter Amputation and Reconstructive Options

OBJECTIVE

This study aimed to present the results of a series of forequarter amputations (FQAs) and to evaluate the reconstructive methods used.

SUMMARY BACKGROUND DATA

Although FQA has become a rare procedure in the era of limb-sparing treatment of extremity malignancies, it is a useful option when resection of a shoulder girdle or proximal upper extremity tumor cannot be performed so as to retain a functional limb.

METHODS

Thirty-four patients were treated with FQA in 1989 to 2017. Various reconstructive techniques were used, including free fillet flaps from the amputated extremity.

RESULTS

All patients presented with intractable symptoms such as severe pain, motor or sensory deficit, or limb edema. Seventeen patients were treated with palliative intent. Chest wall resection was performed in 9 patients. Free flap reconstruction was necessary for 15 patients, with 11 free flaps harvested from the amputated extremity. There was no operative mortality, and no free flaps were lost. In curatively treated patients, estimated 5-year disease-specific survival was 60%. Median survival in the palliatively treated group was 13 months (1-35 months).

CONCLUSIONS

Limb-sparing treatment is preferable for most shoulder girdle and proximal upper extremity tumors. Sometimes, FQA is the only option enabling curative treatment. In palliative indications, considerable disease-free intervals and relief from disabling symptoms can be achieved. The extensive tissue defects caused by extended FQA can be safely and reliably reconstructed by means of free flaps, preferably harvested from the amputated extremity.

Reconstruction of complex hemipelvectomy defects: A 17-year single-institutional experience with lower extremity free and pedicled fillet flaps

INTRODUCTION

Hemipelvectomy procedures result in massive soft tissue defects. The standard approach is to reconstruct the defect with anterior or posterior hemipelvectomy flaps. Certain situations preclude the use of local tissue flaps, and an alternative is the use of leg fillet flaps, circumferential pedicled or free flaps harvested from the amputated part. The purpose of this study is to present our institution's experience with using pedicled and free fillet flaps to reconstruct hemipelvectomy soft tissue defects.

METHODS

We performed a retrospective chart review of patients who underwent hemipelvectomy and fillet flap reconstruction from 2001 to 2018. Demographics, clinical and surgical characteristics, postoperative outcomes, and complications of patients were reviewed.

RESULTS

Ten patients were identified and included. Their mean age was 51 ± SD 12.4 years. Six patients underwent standard external hemipelvectomy and 4 patients underwent extended external hemipelvectomy. Seven lower extremity fillet flaps were performed as free tissue transfers, and 3 were pedicled flaps. The mean flap size was 1,153 ± SD 1137 cm². The mean follow-up was 5 months (range: 1-24 months). Five patients developed postoperative complications; none of them required operative intervention. There were no partial or total flap losses postoperatively.

CONCLUSION

Reconstruction with pedicled or free lower extremity fillet flaps is a valuable reconstructive approach, for managing large soft tissue defects following hemipelvectomy when the standard anterior and posterior thigh flaps are unavailable or inadequate for complete soft tissue coverage. This useful technique mitigates donor site morbidity, while simultaneously achieving massive soft tissue coverage with an acceptable complication profile.

Surgical management of soft tissue sarcomas: extremity sarcomas

Wide surgical resection is the recommended treatment for extremity soft tissue sarcomas. Chemotherapy and/or radiotherapy may improve local control, but with marginal effect on overall survival. Advanced reconstructive techniques and multidisciplinary care, including plastic surgery, may allow a higher rate of limb salvage. This report focuses on surgical and reconstructive aspects in the multimodality care of extremity sarcomas.

Transfer of free fillet lateral arm flap for facial reconstruction

We describe a 16-year-old male patient who had a major right facial degloving injury resulting in a soft-tissue defect with exposed zygoma as well as temporal and frontal bones. Multiple operations were undertaken in a staged manner for reconstruction. Lateral arm free fillet flap transfer was initially performed with fixation of bones with miniplates, which is followed by flap debulking, lateral canthopexy, scalp tissue expansion for hairline reconstruction, as well as ear reconstruction with costal cartilage and local flap techniques. After a follow-up period of 2 years, a good and impressive reconstructive result was achieved through the use of multiple contemporary reconstructive procedures after a successful free fillet flap transfer from an amputated part.