A comparison of delayed versus immediate reconstruction following lower-extremity sarcoma resection

A Systematic Review of the Orthoplastic Approach in Adult Lower Extremity Soft Tissue Sarcoma Flap Reconstruction

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.

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.

Immediate Versus Late Flap Coverage for Traumatic Soft Tissue Defects of Lower Extremity: A Comparative Observational Study

Background

The lower extremity trauma in patients often gets operated on late for the wound coverage and is associated with more health costs and other resources. Therefore, this study has been conducted to compare the outcome in terms of flap survival, complication rates, and hospital stay between immediate and late flap coverage of lower extremity traumatic wounds.

Methods

The comparative analysis of outcome is done in terms of flap survival, complication rates, and hospital stay after immediate and late flap coverage of 25 (n = 25) patients of lower extremity traumatic wounds in each group. The patients were observed, and data obtained were tabulated in a Microsoft Excel spreadsheet. The statistical analysis was done using IBM SPSS (V26.0, IBM Corporation, Armonk, NY, USA) statistical software. The chi-square test was used for descriptive data and the student's unpaired t-test for discrete-continuous data analysis. The p-value of less than 0.05 is considered significant.

Results

The mean defect size with SD in the immediate flap cover group is 54.5 ± 29.5 cm2, while in the late flap cover group, it is 85 ± 65 cm2 with a significant p-value of 0.0378. The mean flap size with SD in the immediate flap coverage group is 70.5 ± 34.5 cm2, while in the late flap coverage group, it is 117 ± 87.5 cm2, and the difference is statistically significant. The mean hospital stay with SD in the immediate flap coverage group is 7.5 ± 2.5 days. In contrast, in the late flap coverage group, it is 29.5 ± 8.5 days, and the difference is statistically very significant.

Conclusion

There are equivalent results in patients undergoing immediate and late flap coverage for the traumatic soft tissue defects of the lower extremity. There is a significant decrease in the hospital stay after immediate flap reconstruction, which subsequently reduces both direct and indirect health costs. However, there is a larger size flap requirement in cases of immediate lower extremity wound coverage.