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Karakawa R, Yoshimatsu H, Fuse Y, Tanakura K, Imai T, Sawaizumi M, Yano T. Immediate tendon transfer for functional reconstruction of a dorsal forearm defect after sarcoma resection. J Plast Surg Hand Surg 2023; 57:157-162. [PMID: 35023432 DOI: 10.1080/2000656x.2021.2024556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In the treatment of sarcoma, the reconstructive surgeon must consider not only limb salvage but also functional reconstruction. The aim of this study was to evaluate a functional reconstruction of a dorsal forearm defect after sarcoma resection using immediate tendon transfer. Patients who underwent reconstruction of a dorsal forearm defect after sarcoma resection with an immediate tendon transfer between 1997 and 2019 at our hospital were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics and functional outcomes were examined. Nine patients were included in this study. Tendon transfer of the flexor carpi radialis (FCR) or the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC), the brachioradialis (BR) to the EDC, and the palmaris longus (PL) tendon to the extensor pollicis longus (EPL) was performed in seven, two and five patients, respectively. Seven patients underwent reconstruction using a free flap. Neither anastomosis complications nor infections were encountered. Partial flap necrosis and donor site dehiscence were seen in one case each. The mean distal interphalangeal (DIP), proximal interphalangeal (PIP) and metacarpophalangeal (MP) joint active extension were 4.4°, 6.1° and 11.1° postoperatively. The mean Musculoskeletal Tumor Society (MSTS) score was 26. Immediate tendon transfers of the FCR or the FCU to the EDC and the PL tendon to the EPL can be considered an optimal functional reconstruction of a dorsal forearm defect after sarcoma resection.
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Affiliation(s)
- Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kenta Tanakura
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Imai
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Sawaizumi
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Stiles ZE, Lohman RF, Mann GN. Plastic Surgery Reconstruction of Sarcoma Resection Defects. Surg Clin North Am 2022; 102:583-599. [DOI: 10.1016/j.suc.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Trøstrup H, Bigdeli AK, Krogerus C, Kneser U, Schmidt G, Schmidt VJ. A Multidisciplinary Approach to Complex Dermal Sarcomas Ensures an Optimal Clinical Outcome. Cancers (Basel) 2022; 14:cancers14071693. [PMID: 35406465 PMCID: PMC8996894 DOI: 10.3390/cancers14071693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/21/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022] Open
Abstract
Primary dermal sarcomas (PDS) belong to a highly clinically, genetically and pathologically heterogeneous group of rare malignant mesenchymal tumours primarily involving the dermis or the subcutaneous tissue. The tumours are classified according to the mesenchymal tissue from which they originate: dermal connective tissue, smooth muscle or vessels. Clinically, PDS may mimic benign soft tissue lesions such as dermatofibromas, hypertrophic scarring, etc. This may cause substantial diagnostic delay. As a group, PDS most commonly comprises the following clinicopathological forms of dermal sarcomas: dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), dermal undifferentiated pleomorphic sarcoma (DUPS), leiomyosarcoma (LMS), and vascular sarcomas (Kaposi’s sarcoma, primary angiosarcoma, and radiation-induced angiosarcoma). This clinical entity has a broad spectrum regarding malignant potential; however, local aggressive behaviour in some forms causes surgical challenges. Preoperative, individualised surgical planning with complete free margins is pivotal along with a multidisciplinary approach and collaboration across highly specialised surgical and medical specialties. The present review gives a structured overview of the most common forms of dermal sarcomas including surgical recommendations and examples for advanced reconstructions as well as the current adjunctive medical treatment strategies. Optimal aesthetic and functional outcomes with low recurrence rates can be achieved by using a multidisciplinary approach to complex dermal sarcomas. In cases of extended local tumour invasion in dermal sarcomas, advanced reconstructive techniques can be applied, and the interdisciplinary microsurgeon should be an integral part of the sarcoma board.
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Affiliation(s)
- Hannah Trøstrup
- Department of Plastic Surgery and Breast Surgery, Zealand University Hospital (SUH) Roskilde, University of Copenhagen, 4000 Roskilde, Denmark; (C.K.); (V.J.S.)
- Department of Plastic Surgery and Burns Treatment, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark;
- Correspondence: ; Tel.: +45-47323700
| | - Amir K. Bigdeli
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Heidelberg University, D-67071 Ludwigshafen, Germany; (A.K.B.); (U.K.)
| | - Christina Krogerus
- Department of Plastic Surgery and Breast Surgery, Zealand University Hospital (SUH) Roskilde, University of Copenhagen, 4000 Roskilde, Denmark; (C.K.); (V.J.S.)
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Heidelberg University, D-67071 Ludwigshafen, Germany; (A.K.B.); (U.K.)
| | - Grethe Schmidt
- Department of Plastic Surgery and Burns Treatment, Rigshospitalet, University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Volker J. Schmidt
- Department of Plastic Surgery and Breast Surgery, Zealand University Hospital (SUH) Roskilde, University of Copenhagen, 4000 Roskilde, Denmark; (C.K.); (V.J.S.)
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Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review. J Plast Reconstr Aesthet Surg 2020; 74:755-767. [PMID: 33277214 DOI: 10.1016/j.bjps.2020.10.065] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 06/25/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Upper limb preservation after soft tissue sarcoma (STS) surgical excision is now the accepted gold standard and it often requires reconstruction with free flaps. The purpose of this review is to summarize current literature on upper limb reconstruction with free flaps after STS resection. METHODS A systematic review was performed in July 2019 in PubMed and MedLine Ovid databases according to the PRISMA guidelines. RESULTS A total of 17 studies were included in the final analysis, with 132 patients. The most common diagnosis was Malignant Fibrous Histiocytoma. The most frequent timing of flap coverage was immediate. The success rate was almost always 100%. The length of follow-up was reported in 11 studies with a range of 2-187 months. The most commonly reported patient-centered outcome was the MSTS Score. Based on the evidence of the literature collected, we divided the upper limb into four parts (shoulder, elbow and arm, forearm and wrist, and hand) and described the most common and functional free flaps used for reconstruction after STS resection. CONCLUSIONS Free flaps in the treatment of STS of the upper extremity have a good overall outcome, with a low postoperative complication rate. A wide array of free flaps is available for reconstruction, and the choice of flap is based on defect size, types of tissue required, postoperative functional goal, and surgeon preference. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.
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Kreutz‐Rodrigues L, Mohan AT, Moran SL, Carlsen BT, Mardini S, Houdek MT, Rose PS, Bakri K. Extremity free fillet flap for reconstruction of massive oncologic resection—Surgical technique and outcomes. J Surg Oncol 2019; 121:465-473. [DOI: 10.1002/jso.25795] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/08/2019] [Indexed: 11/08/2022]
Affiliation(s)
| | - Anita T. Mohan
- Division of Plastic Surgery, Department of SurgeryMayo Clinic Rochester Minnesota
| | - Steven L. Moran
- Division of Plastic Surgery, Department of SurgeryMayo Clinic Rochester Minnesota
- Department of Orthopedic SurgeryMayo Clinic Rochester Minnesota
| | - Brian T. Carlsen
- Division of Plastic Surgery, Department of SurgeryMayo Clinic Rochester Minnesota
- Department of Orthopedic SurgeryMayo Clinic Rochester Minnesota
| | - Samir Mardini
- Division of Plastic Surgery, Department of SurgeryMayo Clinic Rochester Minnesota
| | | | - Peter S. Rose
- Department of Orthopedic SurgeryMayo Clinic Rochester Minnesota
| | - Karim Bakri
- Division of Plastic Surgery, Department of SurgeryMayo Clinic Rochester Minnesota
- Department of Orthopedic SurgeryMayo Clinic Rochester Minnesota
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Whiles E, Joshi H, Jenyo O, Perumalthiagarajan A, Oyibo SO. Undifferentiated Pleomorphic Sarcoma of the Hand with Lung Metastases. Cureus 2019; 11:e5557. [PMID: 31523591 PMCID: PMC6728777 DOI: 10.7759/cureus.5557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Undifferentiated pleomorphic sarcoma (UPS) is a rare tumor of mesenchymal origin affecting the hand in less than 3% of cases. A 92-year-old male reported an enlarging, painless mass on his left hand of three months duration. Examination of the hand revealed a soft, non-tender, immobile mass over the wrist joint, just proximal to his thumb. Immunohistochemistry findings on ultrasound-guided biopsy were consistent with UPS. Further intractable pain, ulceration, and bleeding necessitated urgent radiotherapy, which provided no relief. This was followed by amputation above the elbow. Seven months later, the patient presented with confusion. A chest X-ray revealed extensive bilateral pulmonary metastases. In light of this result, the patient was referred to the palliative care team. UPS carries a poor prognosis, with a high risk of metastases. Early diagnosis and treatment is required for optimal clinical outcomes. Through this case, we highlight the need for a more effective treatment strategy to improve clinical outcomes.
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Affiliation(s)
- Emily Whiles
- General Surgery, Peterborough City Hospital, Peterborough, GBR
| | - Hareesh Joshi
- Internal Medicine, Peterborough City Hospital, Peterborough, GBR
| | - Olukunle Jenyo
- Diabetes and Endocrinology, Peterborough City Hospital, Peterbourough, GBR
| | | | - Samson O Oyibo
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
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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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Simultaneous reconstruction of the forearm extensor compartment tendon, soft tissue, and skin. Arch Plast Surg 2018; 45:479-483. [PMID: 30282421 PMCID: PMC6177635 DOI: 10.5999/aps.2017.01802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/17/2018] [Indexed: 11/24/2022] Open
Abstract
Malignant peripheral nerve sheath tumor (MPNST) is a very rare type of sarcoma, with an incidence of 0.001%. MPNST has a 5-year survival rate near 80%, so successful reconstruction techniques are important to ensure the patient’s quality of life. Sarcoma of the forearm is known for its poor prognosis, which leads to wider excision, making reconstruction even more challenging due to the unique anatomical structure and delicate function of the forearm. A 44-year-old male presented with a large mass that had two aspects, measuring 9×6 cm and 7×5 cm, on the dorsal aspect of the right forearm. The extensor compartment muscles (EDM, EDC, EIP, EPB, EPL, ECRB, ECRL, APL) and invaded radius were resected with the mass. Tendon transfer of the entire extensor compartment with skin defect coverage using a 24×8 cm anterolateral thigh (ALT) perforator free flap was performed. The patient was discharged after 18 days without wound complications, and has not complained of discomfort during supination, pronation, or wrist extension/flexion through 3 years of follow-up. To our knowledge, this is the first report of successful reconstruction of the entire forearm extensor compartment with ALT free flap coverage after resection of MPNST.
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A Longitudinal Study of Functional Outcomes in Patients with Limb Salvage Surgery for Soft Tissue Sarcoma. Sarcoma 2018; 2018:6846275. [PMID: 30123044 PMCID: PMC6079357 DOI: 10.1155/2018/6846275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 01/08/2018] [Accepted: 02/26/2018] [Indexed: 01/13/2023] Open
Abstract
Background Many studies have reported on the surgical outcomes of soft tissue sarcoma. However, there was no longitudinal cohort study. Because time is the most valuable factor for functional recovery, adjusting time value was the key for finding the causal relationship between other risk factors and postoperative function. Therefore, existing cross-sectional studies can neither fully explain the causal relationship between the risk factors and the functional score nor predict functional recovery. The aim of this study was to determine important predictive factors that affect postoperative functional outcomes and longitudinal changes in functional outcomes in patients who had undergone limb-sparing surgery (LSS) for soft tissue sarcoma (STS). Methods Between January 2008 and December 2014, we retrospectively enrolled 150 patients who had undergone LSS for STS and had been assessed for postoperative functional outcomes with questionnaires. To evaluate functional outcomes, we used the Musculoskeletal Tumor Society (MSTS) score and Toronto Extremity Salvage Score (TESS). Multivariate generalized estimating equation (GEE) analysis was used to identify the predictive factors, including size, stage, and anatomic location of tumor, bone resection, flap reconstruction, age, and time after surgery. Each continuous variable such as age and time after surgery was explored for statistically significant cutoff points using the Wilcoxon rank sum test. Results Functional scores significantly improved until the second year after surgery and plateaued for the rest of the 5-year period. Age (p < 0.0001), bone resection (p=0.0004), and time after surgery (p < 0.0001) were identified as significant predictive factors. The functional score was significantly higher in patients younger than 47 years old. Conclusions Functional outcomes can improve until the second year after surgery. Patients who were older than 47 and underwent bone resection may have poor final functional outcomes.
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Reddy VS, Sierakowski A, Periasamy M, Sabapathy SR. Primary Index Finger Pollicization for Thumb Reconstruction Following Soft Tissue Sarcoma Excision. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2015; 20:453-7. [PMID: 26388009 DOI: 10.1142/s0218810415720181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Soft tissue sarcomas in the thumb are rare, but often require amputation to ensure tumour clearance. This can severely impair the use of the entire upper limb and negatively impact quality of life. We describe a 63-year-old male patient with a large malignant fibrous histiocytoma affecting the base of his dominant right thumb. A wide resection of this tumour was performed, followed immediately by index finger pollicization and first web space reconstruction with a reverse pedicled posterior interosseous artery flap. The patient was able to continue using his right hand for functions of daily living and was free from local recurrence until he died from distant metastases 2 years later. Primary thumb reconstruction following amputation for sarcoma can allow a patient to retain useful hand function postoperatively. Provided that strict principles of tumour clearance are adhered to, this need not compromise local recurrence rates.
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Affiliation(s)
- Velagala Satyanarayana Reddy
- 1 Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery & Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Adam Sierakowski
- 1 Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery & Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Madhu Periasamy
- 1 Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery & Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Shanmuganathan Raja Sabapathy
- 1 Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery & Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
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Baroudi MR, Ferguson PC, Wunder JS, Isler MH, Mottard S, Werier JA, Turcotte RE. Forearm soft tissue sarcoma: Tumors characteristics and oncologic outcomes following limb salvage surgery. J Surg Oncol 2014; 110:676-81. [DOI: 10.1002/jso.23686] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 05/19/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Maher R. Baroudi
- Orthopaedic Surgery; Montreal General Hospital; Montreal Quebec Canada
| | | | - Jay S. Wunder
- Orthopaedic Surgery; Mount Sinai Hospital; Toronto Ontario Canada
| | - Marc H. Isler
- Orthopaedic Surgery; Maisonneuve-Rosemont Hospital; Montreal Quebec Canada
| | - Sophie Mottard
- Orthopaedic Surgery; Maisonneuve-Rosemont Hospital; Montreal Quebec Canada
| | - Joel A. Werier
- Orthopaedic Surgery; The Ottawa Hospital; Ottawa Ontario Canada
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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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Payne CE, Hofer SOP, Zhong T, Griffin AC, Ferguson PC, Wunder JS. Functional outcome following upper limb soft tissue sarcoma resection with flap reconstruction. J Plast Reconstr Aesthet Surg 2013; 66:601-7. [PMID: 23434111 DOI: 10.1016/j.bjps.2013.01.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 01/27/2013] [Accepted: 01/28/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Upper limb preservation after soft tissue sarcoma resection often requires flap reconstruction. The aim of this study was to compare pre- and post-operative upper limb function following shoulder, elbow or wrist/hand sarcoma resection and soft tissue reconstruction with a pedicled or free flap. PATIENTS Between 1989 and 2008, 113 patients underwent resection of an upper limb soft tissue sarcoma and required flap reconstruction. Perioperative morbidity, mortality and flap loss were studied. Functional outcome was assessed pre and postoperatively using the Toronto Extremity Salvage Score (TESS), a measure of disability, and the Musculoskeletal Tumour Society Rating Scale (MSTS), a measure of impairment. Statistical analyses were performed to evaluate the relationship between flap type and functional outcome scores. RESULTS Patients underwent soft tissue sarcoma excision in the shoulder (n = 64), elbow (n = 27) or wrist/hand (n = 22) region with soft tissue reconstruction using either a pedicled (n = 76) or free flap (n = 37). Comparison of the post-operative MSTS (n = 88) and TESS (n = 84) revealed no significant differences between the free and pedicled flap groups. A significant pre- to post-operative difference was identified in MSTS 87 scores for patients in both the pedicled (p < 0.02) and free flap groups (p < 0.04). Comparison of the pre- and post-operative MSTS 93 scores also revealed a significant difference (p < 0.01) but this was limited to the free flap group. The most notable post-operative score reductions in these patients were due to major joint, nerve, tendon or muscle group resection. CONCLUSION Reconstruction of the soft tissue defect following sarcoma resection in the upper limb maintains a similar satisfactory level of upper limb activity with either pedicled or free flap reconstructions. Based on TESS scores, patients rated themselves as having better function compared to impairment measures such as MSTS.
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Affiliation(s)
- Caroline E Payne
- Division of Plastic Surgery, University Health Network, University of Toronto, Toronto, Canada
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Selber JC, Treadway C, Lopez A, Lewis VO, Chang DW. The use of free flap for limb salvage in children with tumors of the extremities. J Pediatr Surg 2011; 46:736-744. [PMID: 21496546 DOI: 10.1016/j.jpedsurg.2010.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 09/01/2010] [Accepted: 09/03/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate long-term functional outcomes in pediatric oncology patients who underwent limb salvage using free flaps. METHODS All 22 pediatric oncology patients treated with a free flap for extremity salvage were included in the study from 1999 to 2008. RESULTS The median patient age was 13.5 years. All but one patient had sarcoma, which involved lower extremity in 45% and upper extremity in 55%. The median bone defect length was 13.9 cm: reconstructed with vascularized free fibula in 68% (in 23% osseous allograft was also used) and used fibula growth plate transfer in 23%. The mean soft tissue defect area was 108 cm(2): reconstructed with latissimus dorsi flap in 4 patients, vertical rectus abdominus muscle flap in 2, and anterolateral thigh flap in 1. The majority of the complications were nonunion (14%) and wound infection/dehiscence (14%). The median Musculoskeletal Tumor Society score was 70. Patients with tumors in the upper extremity had significantly higher Musculoskeletal Tumor Society scores compared with lower extremity tumor patients (80 vs 50, P = .04); and among those with lower extremity tumors, patients with distal defects had better outcomes than patients with proximal defects (70 vs 40, P = .03). CONCLUSION In pediatric oncology patients who need limb salvage, use of free flaps can result in good long-term functional outcomes.
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Affiliation(s)
- Jesse C Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Christen Treadway
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Adriana Lopez
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Valerae O Lewis
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - David W Chang
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Davidge KM, Wunder J, Tomlinson G, Wong R, Lipa J, Davis AM. Function and health status outcomes following soft tissue reconstruction for limb preservation in extremity soft tissue sarcoma. Ann Surg Oncol 2010; 17:1052-62. [PMID: 20107912 DOI: 10.1245/s10434-010-0915-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND While advances in reconstructive surgery have facilitated limb preservation in extremity soft tissue sarcoma (ESTS), limited information exists as to the functional outcome of patients with these reconstructed extremities. The primary objective of this study is to evaluate the impact of flap reconstruction on postoperative function and health status in patients undergoing limb-salvage surgery for ESTS. METHODS Clinical and outcome data for eligible patients were extracted from a prospectively maintained database of sarcoma patients. Four outcome measures were used to assess three domains of function (impairments, activity limitations, and participation restrictions), and health status. The effect of soft tissue reconstruction on function and health status at 1-2-year follow-up was analyzed using univariate and multivariate regression. RESULTS Two hundred and forty-seven patients met eligibility criteria, including 56 patients receiving flap reconstruction and 191 patients treated with primary closure. Patients receiving flaps had larger (9.8 versus 7.1 cm; P = 0.003), higher-grade (93% versus 72%; P = 0.001) tumors, and more frequently received radiotherapy (89% versus 72%; P = 0.007), and bone (20% versus 4%; P = 0.001) and motor nerve resection (21% versus 10%; P = 0.032). Flap reconstruction was associated with more postoperative impairments [Musculoskeletal Tumor Society (MSTS) score 30.4 versus 32.2; P = 0.004] and activity limitations [Toronto Extremity Salvage Score (TESS) score 83.3 versus 89.5; P = 0.0132] on univariate analyses, but did not significantly predict postoperative function or health status outcomes on multivariate analyses. CONCLUSIONS Flap reconstruction was not an independent predictor of function and health status outcomes in patients with ESTS. However, ESTS patients receiving flaps had other clinical features placing them at risk for worse postoperative outcomes.
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Affiliation(s)
- Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Canada.
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Barner-Rasmussen I, Popov P, Böhling T, Blomqvist C, Tukiainen E. Microvascular reconstructions after extensive soft tissue sarcoma resections in the upper limb. Eur J Surg Oncol 2010; 36:78-83. [DOI: 10.1016/j.ejso.2009.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 08/03/2009] [Accepted: 08/06/2009] [Indexed: 10/20/2022] Open
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Misra A, Mistry N, Grimer R, Peart F. The management of soft tissue sarcoma. J Plast Reconstr Aesthet Surg 2008; 62:161-74. [PMID: 19036655 DOI: 10.1016/j.bjps.2008.08.018] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 07/14/2008] [Accepted: 08/12/2008] [Indexed: 11/19/2022]
Abstract
SUMMARY Soft tissue sarcomas are a rare group of mesenchymal tumours that display cardinal signs, which can raise suspicion to their diagnosis. Management in a sarcoma treatment centre by its multidisciplinary team has improved outcome. Good local disease control with limb salvage and adjuvant radiotherapy has considerably reduced the morbidity of previous limb amputation. By the early involvement of a plastic surgeon, tissue reconstruction is optimised and wound complications reduced. This article looks at the contemporary management of soft tissue sarcoma and, in particular, its relevance to the plastic surgeon today.
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Affiliation(s)
- A Misra
- Royal Orthopaedic Hospital, Bristol Road South, Northfield, Birmingham, UK
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Labow BI, Rosen H, Greene AK, Lee WP, Upton J. Soft tissue sarcomas of the hand: functional reconstruction and outcome analysis. Hand (N Y) 2008; 3:229-36. [PMID: 18780101 PMCID: PMC2525882 DOI: 10.1007/s11552-008-9089-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Accepted: 02/15/2008] [Indexed: 11/27/2022]
Abstract
Functional hand reconstruction following treatment of soft tissue sarcomas (STS) is a difficult surgical problem. Because survival rates between amputation and limb salvage do not differ, there is a trend toward reconstruction. Unlike amputation, hand salvage usually requires multiple complex operations in combination with adjuvant radiation or chemotherapy, prolonged rehabilitation, and carries a high complication rate. We investigated tumor recurrence, survival, and scored functional outcomes to determine if limb salvage is justified after hand STS resection. Patients treated for hand STS between years 1985 and 2005 were reviewed by two surgeons in three medical centers. All patients having functional reconstruction instead of amputation were reviewed. Patient demographics, tumor type and grade, resection extent, reconstruction procedure, timing, adjuvant therapy use, complications, tumor recurrence, survival, and functional outcome were recorded and analyzed. Five patients underwent functional reconstruction for hand STS. All patients underwent attempted curative resections, and four patients received neoadjuvant or postoperative radiation therapy. Three patients received adjuvant chemotherapy. Reconstructive techniques included three modified pollicizations, one free-tissue transfer, and one groin flap. All patients were alive and disease-free at a mean follow-up of 5 years (range 1.5-17 years). Three patients (60%) had local complications, requiring secondary surgeries. Two complications were related to radiation therapy. Hand function was evaluated using the Enneking Scoring System, and ranged from 17 to 28. The average Enneking score was 22.4, representing an average preservation of 74.6% of function. Because most patients retain excellent function and survival is unaffected, we advocate functional reconstruction despite high complication rates.
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Affiliation(s)
- Brian I. Labow
- Divisions of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, MA USA ,Department of Plastic Surgery, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Heather Rosen
- Harvard Medical School, Harvard School of Public Health, Boston, MA USA
| | - Arin K. Greene
- Divisions of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, MA USA ,Department of Plastic Surgery, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
| | | | - Joseph Upton
- Divisions of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, MA USA ,Department of Plastic Surgery, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
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Temple CLF, Ross DC, Magi E, DiFrancesco LM, Kurien E, Temple WJ. Preoperative chemoradiation and flap reconstruction provide high local control and low wound complication rates for patients undergoing limb salvage surgery for upper extremity tumors. J Surg Oncol 2007; 95:135-41. [PMID: 17262730 DOI: 10.1002/jso.20629] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Neoadjuvant protocols in the management of upper extremity sarcoma have improved local control rates but have been associated with high complication rates. We present a refinement of the Eilber protocol using judicious preoperative chemoradiation, limb salvage surgery, and flap coverage to achieve high local control rates with acceptable wound healing complications. METHODS Patients presenting with upper extremity neoplasms from 1986 to 2002 were treated with a modified Eilber protocol, consisting of 3 days of adriamycin (30 mg/day) and sequential radiotherapy (300 cGy/day for 10 days). Limb salvage surgery with flap coverage where needed was performed 4-8 weeks later. Patients were followed prospectively for recurrence. RESULTS Fifty-three consecutive patients with upper extremity tumors were treated and followed for a mean of 6.1 years. This cohort included 44 sarcomas and nine non-metastasizing, locally aggressive tumors. There were two local recurrences (3.8%). Limb salvage was achieved in all patients. Flaps were required in 43.4% of patients. Major complications occurred in 11%, were all flap related (partial flap loss, venous congestion), and went on to heal promptly with treatment. CONCLUSION This modified Eilber protocol achieved 96% local control for upper extremity tumors with a wound complication rate of 11%. The liberal use of flaps of resulted in healed, stable wounds in all patients.
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Affiliation(s)
- C L F Temple
- Division of Plastic Surgery, University of Western Ontario, Ontario, Canada.
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Kremer T, Bickert B, Germann G, Heitmann C, Sauerbier M. Outcome Assessment after Reconstruction of Complex Defects of the Forearm and Hand with Osteocutaneous Free Flaps. Plast Reconstr Surg 2006; 118:443-54; discussion 455-6. [PMID: 16874216 DOI: 10.1097/01.prs.0000227742.66799.74] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complex defects of the forearm and hand often require microvascular reconstruction with osteocutaneous free flaps for limb salvage. METHODS Fifteen patients with osseous and soft-tissue defects of the forearm and hand were treated with osteocutaneous flaps (1992 to 2004) and evaluated for postoperative results. Assessment focused on range of motion, pain, grip strength, and Disabilities of Arm, Shoulder, and Hand questionnaire score. Donor- and recipient-site morbidity was documented. RESULTS The defects resulted from trauma, infection, or malignancy. Reconstruction was possible by microvascular osteoseptocutaneous fibula transplantation (n = 8), osteocutaneous scapular or parascapular flaps(n = 6), and osteocutaneous lateral arm flap (n = 1). The average patient age was 38 years. The median osseous defect was 11.7 cm, and all patients needed additional soft-tissue reconstruction. All defects could be reconstructed in a one-step procedure after serial débridement or oncologic resection. Patients' hand function was markedly reduced compared with the unaffected extremity, but functional results were still satisfactory, with a mean Disabilities of Arm, Shoulder, and Hand score of 25.3 reflecting a moderate disability in activities of daily living. Two patients developed pseudarthrosis, and one had to undergo an ablation procedure because of persistent infection. Two patients developed wound dehiscence at the donor site, and one patient required a fasciotomy due to an imminent compartment syndrome after fibula harvest. For all patients, the functional results were acceptable when the potential alternatives were taken into consideration. This was also reflected by a high individual satisfaction rate. CONCLUSION This analysis demonstrates that limb salvage with osteocutaneous free flaps is the treatment of choice for three-dimensional defects of the forearm and hand.
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Affiliation(s)
- Thomas Kremer
- Department of Hand, Plastic, and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Plastic and Hand Surgery, The University of Heidelberg, Ludwigshafen, Germany
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