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Abe Y, Nagasaka S, Yamashita Y, Mineda K, Yamasaki H, Bando M, Mima S, Hashimoto I. Functional outcomes of reconstructive flap surgery for soft tissue sarcoma: Long-term outcomes of functional restoration using innervated muscle transplantation. J Plast Reconstr Aesthet Surg 2024; 91:312-321. [PMID: 38442511 DOI: 10.1016/j.bjps.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/11/2023] [Accepted: 02/04/2024] [Indexed: 03/07/2024]
Abstract
Functional outcomes associated with prognostic factors and innervated muscle transplantation after wide soft tissue sarcoma resection remain unclear. We retrospectively examined the functional outcomes of reconstructive flap surgery for soft tissue sarcoma. Twenty patients underwent innervated muscle transplantation with pedicled or free flaps for functional reconstruction of resected muscles. Thirteen latissimus dorsi muscles and one vastus lateralis muscle combined with an anterolateral thigh flap were transferred as free flaps using the epi-perineural suture technique. Six latissimus dorsi muscles were transferred as pedicled flaps with neural continuity. Postoperative functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) scores for the upper and lower extremities of 22 and 24 patients, respectively. The mean MSTS score for all patients was 82.3 at 12 months postoperatively. The mean scores for patients who underwent reconstruction with pedicled and free flaps were 89.2 and 77.1, respectively. The MSTS scores for the lower extremity, tumor size ≥5 cm, and free flap reconstruction were significantly lower than those for the upper extremity, tumor size <5 cm, and pedicled flap reconstruction (P = 0.02, 0.37, and 0.008, respectively). The postoperative MSTS score for innervated muscle transplantation was 76.7 at 12 months and was significantly higher (83.7) at 24 months (P = 0.003). Functional outcomes were significantly associated with tumor location, tumor size, and reconstructive flap type based on the MSTS scores. Innervated muscle transplantation improved functional outcomes at 24 months postoperatively via sufficient recovery of the innervated muscle, not the compensatory recovery of the remaining muscle.
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Affiliation(s)
- Yoshiro Abe
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan.
| | - Shinji Nagasaka
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yutaro Yamashita
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kazuhide Mineda
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hiroyuki Yamasaki
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Mayu Bando
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shunsuke Mima
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Ichiro Hashimoto
- Department of Plastic and Reconstructive Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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LaValley MN, Dugue D, Diaddigo SE, Kuonqui KG, Tyler WK, Bogue JT. A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202403000-00001. [PMID: 38421606 PMCID: PMC10906598 DOI: 10.5435/jaaosglobal-d-23-00290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND The orthoplastic approach to patient care has changed the way patients with a wide variety of lower extremity pathology are treated. Through a systematic review, we aim to analyze outcomes in adult patients with lower extremity soft tissue sarcomas who undergo an orthoplastic flap management approach to their care. METHODS A systematic review of adult lower extremity soft tissue sarcoma excision with plastic surgery flap reconstruction was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines searching the Pubmed, Embase, and Web of Science databases from inception to April 2023. RESULTS After removal of duplicates, title and abstract screening, and full-text review, 26 articles were accepted for inclusion. The total mean follow-up duration was 32.0 ± 24.3 months. Reconstruction used microvascular free flaps in 65.5% (487/743), while 34.5% (256/743) were local flaps. 85.8% (307/358) of patients ambulated postoperatively. Revision surgery was required in 21% of patients during their respective follow-up periods. The limb salvage rate was 93.4% (958/1,026). Among pooled surgical outcomes, 22.2% (225/1,012) of patients experienced a perioperative complication. DISCUSSION Our study demonstrates that although complication rates in lower extremity soft tissue sarcoma reconstruction may be further optimized, a multidisciplinary flap reconstructive approach provides high rates of limb salvage and functional postoperative ambulation.
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Affiliation(s)
- Myles N. LaValley
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - David Dugue
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Sarah E. Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Kevin G. Kuonqui
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Wakenda K. Tyler
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
| | - Jarrod T. Bogue
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center (Mr. LaValley, Dr. Dugue, Ms. Diaddigo, Mr. Kuonqui, and Dr. Bogue), and the Department of Orthopedic Surgery, New York-Presbyterian Hospital/Columbia University Medical, New York, NY (Dr. Tyler)
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Guzzini M, Ciclamini D, Arioli L, Titolo P, Carrozzo A, Latini F, Battiston B, Ferretti A. Correlation between Risk Factors and Healing Times in Long Bone Nonunions Treated with Corticoperiosteal Flap from the Medial Femoral Condyle. J Reconstr Microsurg 2023; 39:502-507. [PMID: 36577498 DOI: 10.1055/a-2004-2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The rate of fracture nonunion varies depending on the anatomical site. Numerous procedures have been proposed to treat recalcitrant nonunions. The vascularized medial femoral condyle corticoperiosteal free flap (MFCCFF) is increasingly used in nonunions with small bone loss.The percentage of success of the MFCCFF is high but the factors involved in delayed bone healing or failure of this technique or the contraindications are not described in the literature.This multicentric study aims to identify and report the different factors involved in determining the time of bone healing in the treatment of atrophic nonunion of long bones with the vascularized medial MFCCFF. METHODS All patients who underwent vascularized medial MFCCFF from January 2011 to December 2020 for the treatment of recalcitrant atrophic nonunions of long bones. Patients were reviewed at 2 and 6 weeks, and 3, 6, and 12 months postoperatively and evaluated by physical and radiographic examinations and patient-reported outcome measures. RESULTS The final study population comprised 59 patients with a mean follow-up of 26.2 ± 7.6 months, a rate of bone healing of 94.9% with a mean radiographic bone healing time of 4.1 ± 1.3 months, and low morbidity of the donor site. Diabetes mellitus, a body mass index (BMI) ≥30 kg/m2, and ≥2 previous surgeries on the fracture site were factors predicting timing for bone healing at the multivariate analysis. CONCLUSION This study demonstrates the MFCCFF as an effective and safe procedure for the treatment of the recalcitrant atrophic nonunion of long bones. An association was found between the lengthening of bone healing time and a high BMI, presence of ≥2 previous surgical interventions, and diabetes mellitus, indicating these comorbidities as risk factors (not absolute contraindications) for this microsurgical treatment. So, to our knowledge, the MFCCFF could be the first-choice treatment for atrophic nonunion of long bones.
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Affiliation(s)
- Matteo Guzzini
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Davide Ciclamini
- Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Leopoldo Arioli
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Paolo Titolo
- Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Alessandro Carrozzo
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Francesca Latini
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Bruno Battiston
- Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Andrea Ferretti
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
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Abstract
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.
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Affiliation(s)
- David M Aten
- From the Departments of Medical Graphics and Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Edward I Chang
- From the Departments of Medical Graphics and Plastic Surgery, University of Texas M. D. Anderson Cancer Center
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Kallenberger AK, Xiong L, Gazyakan E, Ziegler B, Will P, Kneser U, Hirche C. Intraoperative Heparin Bolus and Postoperative Anticoagulation with Low Molecular Weight Heparin Increase Reliability of Microsurgical Free Flaps for Upper Extremity Reconstruction. J Reconstr Microsurg 2022; 39:334-342. [PMID: 35952676 DOI: 10.1055/s-0042-1755264] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
BACKGROUND Microsurgery is an indispensable tool of upper extremity reconstruction addressing defect coverage and the restoration of function. Perioperative anticoagulation and antiplatelet therapy are controversially discussed with impact on microsurgical outcome, but without clear evidence. This study aims to evaluate the impact of perioperative anticoagulation and antiplatelet therapy in microsurgical upper extremity reconstruction. METHODS All eligible patients treated with microsurgical upper extremity reconstruction between January 2000 and July 2014 were included in a comparative analysis to define a superior anticoagulation and antiplatelet regime in a retrospective study. Endpoints were all major complications (e.g., total flap loss, arterial and venous thrombosis) as well as minor complication. RESULTS A total of 183 eligible free flaps to the upper extremity were transferred in 169 patients. Altogether, 11 arterial (6.0%) and 9 venous (4.9%) thromboses, 11 total flap losses (6.0%), and 16 cases with hematoma (8.7%) were detected. In the subgroup analysis, patients who did not receive any heparin intraoperatively (n = 21; 11.5%) had a higher rate of major complications (p = 0.001), with total flap loss being the most frequent event (p = 0.004). A trend was shown for intraoperative bolus administration of 501 to 1,000 units unfractionated heparin (UFH) intravenously to have the lowest rate of major complications (p = 0.058). Intraoperative administration of acetylsalicylic acid (n = 13; 8.1%) did not have any influence on the rate of major complications. Postoperative anticoagulation with continuous UFH intravenously (n = 68; 37.2%) resulted in more frequent complications (p = 0.012), for example, an increased rate of total flap loss (p = 0.02) and arterial thrombosis (p = 0.02). CONCLUSION The results of the present study favor administration of 501 to 1,000 units UFH intravenously as an intraoperative bolus (e.g., 750 units UFH intravenously). Postoperative low molecular weight heparin subcutaneous application in a prophylactic dose given once or twice a day was associated with less complications compared with continuous infusion of UFH, although continuously applied UFH may reflect an increased risk profile.
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Affiliation(s)
- Ann-Katrin Kallenberger
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic and Hand Surgery, Burn Center, St. Georg Hospital gGmbH Leipzig, Leipzig, Germany
| | - Lingyun Xiong
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Benjamin Ziegler
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, University of Frankfurt, Frankfurt, Germany
| | - Patrick Will
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Centre Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic, Hand and Reconstructive Microsurgery, Hand-Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, University of Frankfurt, Frankfurt, Germany
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6
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de Berker HT, Čebron U, Bradley D, Patel V, Berhane M, Almas F, Walton G, Eshete M, McGurk M, Martin D, Honeyman C. Outcomes of microsurgical free tissue transfer performed on international surgical collaborations in low-income and middle-income countries: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:2049-2063. [PMID: 35490120 DOI: 10.1016/j.bjps.2022.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/19/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Microsurgical free tissue transfer is the gold standard for reconstruction of significant soft tissue and bony defects following cancer resection and trauma. Many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources or training required to perform microsurgical procedures. Long-term international collaborations have been formed with annual reconstructive programmes conducting microsurgery. AIMS To critically analyze outcomes of microsurgical free tissue transfer performed on international reconstructive collaborations in LMICs. METHODS PRISMA-compliant systematic review and meta-analysis of outcomes for free tissue transfer performed during international collaborations in LMICs using an inverse variance model. The study protocol was published prospectively and registered with PROSPERO (ID: CRD42021225613). RESULTS Seven studies, included 290 flaps on 284 patients. The most common sites requiring reconstruction were Head and neck (53% (n = 153)) and lower limb (7.9% (n = 23)) were lower limb reconstruction. The most common free flaps were radial forearm (22%; n = 64) and anterolateral thigh (18%; n = 51). Total Flap Failure rate was 3.8% (n = 13; 95% confidence interval (CI) = 1.9-6.3%) Overall complication rate was 38% (95% CI =27-48%), with 19% of flaps requiring emergency return to theatre (95% CI =14-26%). Flap salvage was successful in 52% of take-backs (95% CI =15% - 88%). CONCLUSIONS Free flaps performed during international surgical collaborations in LMICs have comparable failure rates to those performed in higher-income settings. However, there are higher complication and take-back rates. This should be taken into account when planning international collaborations. These results should help preoperative counselling and the consent process.
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Affiliation(s)
- Henry T de Berker
- Department of Plastic Surgery, Royal Preston Hospital, Preston, United Kingdom.
| | - Urška Čebron
- Department of Hand, Plastic, Reconstructive and Burn Surgery, University of Tübingen, Tübingen, Germany
| | - Daniel Bradley
- King's College London, Faculty of Dentistry, Oral and Craniofacial Sciences, Guy's Tower, Guy's Hospital, London, United Kingdom
| | - Vinod Patel
- Oral Surgery Department, Guy's Dental Institute, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Meklit Berhane
- Department of Plastic and Reconstructive Surgery, ALERT Hospital, Addis Ababa, Ethiopia
| | - Fernando Almas
- Department of Cranio-Maxillofacial and Reconstructive Surgery, Saint Judes General Hospital, Federal Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gary Walton
- Department of Head and Neck Surgery, University Hospitals Coventry and Warwickshire, United Kingdom
| | - Mekonen Eshete
- Department of Surgery, School of Medicine, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia
| | - Mark McGurk
- Department of Head and Neck Surgery, University College London Hospital, London, United Kingdom
| | | | - Calum Honeyman
- Canniesburn Plastic Surgery and Burns Unit, Glasgow, Scotland, United Kingdom
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Are Perforators Reliable as Recipient Arteries in Lower Extremity Reconstruction? Analysis of 423 Free Perforator Flaps. Plast Reconstr Surg 2022; 149:750-760. [PMID: 35080525 DOI: 10.1097/prs.0000000000008873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator flaps have revolutionized lower limb reconstruction by offering single-stage thin, pliable coverage with an excellent aesthetic match. Although anastomosis of the flap to a major artery remains the gold standard, perforator-to-perforator anastomosis has several advantages, including expedient recipient dissection and increased recipient options in vessel-depleted extremities. The aim of this study was to compare flap survival when a perforator or major artery was used as a recipient vessel. METHODS A retrospective cohort of free perforator flaps for lower limb reconstruction was reviewed. Demographics, comorbidities, vascular status, defect characteristics, operative details, and complications were recorded. Outcomes for perforator and major artery recipients were compared. RESULTS Four hundred twenty-three flaps were performed for various reasons using perforator flaps. The total limb salvage rate was 98.8 percent. Total and partial flap failure rates were 6.1 percent and 9.0 percent, respectively. Comparing perforator recipients [n = 109 (25.8 percent)] to major artery recipients [n = 314 (74.2 percent)], there was no significant difference in total (p = 0.746) or partial flap failure (p = 0.212). Significant factors between the groups included larger flap size with major artery recipients (p = 0.001) and shorter operative time when using a perforator recipient (p = 0.012). CONCLUSIONS Perforator-to-perforator anastomosis is a reliable option that affords equivalent rates of flap success compared to major artery anastomosis in lower extremity reconstruction. The authors advocate using a major artery recipient in defects where the axial vessels are easily accessible. A perforator recipient is a viable alternative in defects where access to the axial vessels is inconvenient and in patients with limited recipient options. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Abstract
Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.
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Gazyakan E, Xiong L, Sun J, Kneser U, Hirche C. Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures. J Reconstr Microsurg 2021; 37:608-616. [PMID: 33592633 DOI: 10.1055/s-0041-1723823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. METHODS A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. RESULTS A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). CONCLUSION In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.
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Affiliation(s)
- Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Lingyun Xiong
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaming Sun
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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10
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Lese I, Biedermann R, Constantinescu M, Grobbelaar AO, Olariu R. Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers. J Plast Reconstr Aesthet Surg 2020; 74:512-522. [PMID: 33039304 DOI: 10.1016/j.bjps.2020.08.126] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications. METHODS Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index. RESULTS A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p=0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p=0.001). CONCLUSION If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy.
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Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland.
| | - Raphael Biedermann
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
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Kask G, Barner-Rasmussen I, Repo JP, Kjäldman M, Kilk K, Blomqvist C, Tukiainen EJ. Functional Outcome Measurement in Patients with Lower-Extremity Soft Tissue Sarcoma: A Systematic Literature Review. Ann Surg Oncol 2019; 26:4707-4722. [PMID: 31407171 PMCID: PMC6863783 DOI: 10.1245/s10434-019-07698-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Indexed: 12/16/2022]
Abstract
Background The importance of functional outcome (FO) in the treatment of patients with extremity soft tissue sarcoma (STS) has been increasingly recognized in the last three decades. This systematic review aimed to investigate how FO is measured in surgically treated lower-extremity STS patients. Methods A systematic search of PubMed, Web of Science, and Scopus was performed based on the PRISMA guidelines. The methodologic quality of the publications was measured using the MINORS tool. The results from the included studies examining measurement types, measures, and time of FO measurement were compiled. The FO pooled mean and standard deviation were calculated as a weighted average for the groups. The validity of the applied measures is reported. Results The literature search found 3461 publications, 37 of which met the inclusion criteria. The measurement types used were clinician-reported outcomes (n = 27), patient-reported outcomes (n = 20), and observer-reported outcomes (n = 2). The most frequently used measures were the Toronto Extremity Salvage Score (TESS) (n = 16) and the Musculoskeletal Tumor Society (MSTS) score 1993 (n = 12). The postoperative FO was relatively good. The pooled mean TESS and MSTS 1993 scores were respectively 83.3 and 86.2 (out of 100). Of the 10 previously reported measures, 3 provide validated FO scores. The methodologic quality of publications was generally low. Conclusions Based on this systematic review, several different methods exist for assessing FO in patients with lower-extremity sarcoma. The most frequently used measure is a validated TESS. The postoperative FO of patients with lower-extremity STS seems to increase to the preoperative baseline level during long-term follow-up evaluation.
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Affiliation(s)
- Gilber Kask
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland. .,Department of Orthopaedics and Traumatology, Unit of Musculoskeletal Surgery, Tampere University Hospital, Tampere, Finland.
| | - Ian Barner-Rasmussen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland
| | - Jussi Petteri Repo
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Magnus Kjäldman
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland
| | - Kaarel Kilk
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland
| | - Carl Blomqvist
- Helsinki University Hospital Comprehensive Cancer Center, HUS, Helsinki, Finland
| | - Erkki Juhani Tukiainen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland
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13
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Chang EI, Chu CK, Chang EI. Advancements in imaging technology for microvascular free tissue transfer. J Surg Oncol 2018; 118:729-735. [DOI: 10.1002/jso.25194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/10/2018] [Indexed: 11/06/2022]
Affiliation(s)
| | - Carrie K. Chu
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
| | - Edward I. Chang
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
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Complex Reconstruction After Sarcoma Resection and the Role of the Plastic Surgeon: A Case Series of 298 Patients Treated at a Single Center. Ann Plast Surg 2018; 80:59-63. [PMID: 28737559 DOI: 10.1097/sap.0000000000001190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND More than 1000 new patients present to the London Sarcoma Unit each year and between 5% and 10% require plastic surgery intervention. Advancements in radiotherapy and chemotherapy protocols combined with higher expectations for limb preservation has led to increased reconstructive challenges. Frequently, primary closure is achievable; however, larger tumors often require specialist reconstruction. STUDY DESIGN A retrospective chart review of all referred patients from the London Sarcoma Unit requiring reconstruction between February 2006 and January 2015 was performed. Patients who underwent primary amputation were excluded. RESULTS The total number of operations performed was 298 and the mean follow-up was 16 months (12-46 months). 51% of patients had major comorbidities. Patients could be separated into early (0-1 week postoperatively, n = 167) and late reconstructions (>1 week postoperatively, n = 131). 32 patients were reconstructed with skin grafts, 137 patients were managed with regional flaps and 129 patients were treated with free flaps. CONCLUSIONS A patient with 3 or more major comorbidities resulted in a significantly increased risk of reconstructive failure (P < 0.05). Our experience has lead us to adhere to the following guidelines: (1) All patients should be reviewed in a multidisciplinary team meeting. (2) After primary excision, patients should be managed with a vacuum dressing until margins are clear. (3) Definitive reconstruction should be performed by a specialist reconstructive surgeon.
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Starnes-Roubaud MJ, Hanasono MM, Kupferman ME, Liu J, Chang EI. Microsurgical Reconstruction Following Oncologic Resection in Pediatric Patients: A 15-Year Experience. Ann Surg Oncol 2017; 24:4009-4016. [PMID: 28884452 DOI: 10.1245/s10434-017-6061-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Free tissue transfer in the pediatric population is a challenging endeavor, even for experienced microsurgeons. Some surgeons argue these cases can be limited by vessel size and spasticity and should be undertaken only when absolutely necessary. We present a 15-year experience examining outcomes of free tissue transfer in pediatric oncologic patients. METHODS All free flaps performed at a single institution in pediatric patients (age range 3-17) between January 2000 and December 2014 were reviewed. RESULTS Overall, 102 patients (mean age 12.1 ± 4.0 years) were identified who underwent 109 free flaps. The most common flaps were the fibula free flap (46%) and the anterolateral thigh free flap (27%). 81 cases (74%) had malignant disease with 70 cases (64%) involving the head and neck region. 21 cases (19%) had preoperative radiation and 58 cases (53%) had preoperative chemotherapy. 5 cases had total flap loss (4.6%) and 17 cases (15.6%) had immediate post-operative complications, with wound infection (4.6%) being most common. 17 cases (15.6%) had long-term complications with delayed or non-union (4.6%) being most common. Survival rate was 91.7% at 1 year and 78.9% at 5 years. CONCLUSIONS Free tissue transfer is a reliable and appropriate choice in pediatric patients requiring soft tissue or bony reconstruction. Even in pediatric oncologic patients with preoperative chemotherapy or radiation, flap survival and outcomes are comparable to the adult population. Pediatric free tissue transfer should not be avoided but instead considered the gold standard for patients with complex defects, just as it is in the adult population.
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Affiliation(s)
| | - Matthew M Hanasono
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Michael E Kupferman
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Jun Liu
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
| | - Edward I Chang
- Department of Plastic Surgery, MD Anderson Cancer Center, The University of Texas, Houston, TX, USA
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Dobke M, Mackert GA. Upper extremity sarcoma: impact of current practice guidelines and controversies on reconstructive approaches. SICOT J 2017; 3:15. [PMID: 28220751 PMCID: PMC5319376 DOI: 10.1051/sicotj/2017003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/01/2017] [Indexed: 11/15/2022] Open
Abstract
The goals of sarcoma management include both a cure and the functional preservation of involved tissues and adjacent critical structures with common opinions favoring immediate reconstruction. The question arises whether these goals are contradictory. This paper discusses the question based on the experience of 28 patients with different types of extremity sarcoma, with 24 surgically treated by the University of California San Diego (UCSD) orthopedic and plastic surgery team (2011–2016) and the collection of evidence from published practice guidelines, reviews, case studies, and clinical trials. Included are the impact of limb-sparing and functional reconstructive concepts, efforts regarding the adequacy of surgical margins, and the rationale of immediate versus delayed reconstructive approaches, and the disease-free status of sarcoma management.
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Affiliation(s)
- Marek Dobke
- Division of Plastic Surgery, Department of Surgery, University of California San Diego, San Diego, CA 92103-8890, USA
| | - Gina A Mackert
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center, 67071 Ludwigshafen, Germany , the affiliated Department of ptastic surgery of the University of Heidelberg, Germany
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Hussain ON, Sabbagh MD, Carlsen BT. Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities. Clin Plast Surg 2017; 44:299-311. [PMID: 28340664 DOI: 10.1016/j.cps.2016.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.
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Affiliation(s)
- Omar N Hussain
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - M Diya Sabbagh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Brian T Carlsen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA.
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