Abstract
Purpose
Pedicle or free-flap reconstruction is important in surgical sarcoma management. Free flaps are indicated only when pedicle flaps are considered inadequate; however, they are associated with a higher risk of flap failure, longer surgical times, and technical difficulty. To determine the skin defect size that can be covered by a pedicle flap, we investigated the clinical outcomes and complications of reconstruction using pedicle flaps vs. free flaps after sarcoma resection.
Methods
We retrospectively studied the medical records of 24 patients with soft-tissue sarcomas who underwent reconstruction using a pedicle (n = 20) or free flap (n = 4) following wide tumour resection.
Results
All skin defects of the knee, lower leg, and ankle were reconstructed using a pedicle flap. Skin defects of the knee, lower leg, and ankle were covered by up to 525 cm2, 325 cm2, and 234 cm2, respectively. The amount of blood loss was significantly greater in the free-flap group than in the pedicle flap group (p = 0.011). Surgical time was significantly shorter in the pedicle flap group than in the free-flap group (p = 0.006). Total necrosis was observed in one (25%) patient in the free-flap group; no case of total necrosis was observed in the pedicle flap group.
Conclusion
Less blood loss, shorter surgical time, and lower risk of total flap necrosis are notable advantages of pedicle flaps over free flaps. Most skin defects, even large ones, of the lower extremities following sarcoma resection can be covered using a single pedicle flap or multiple pedicle flaps.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data availability
The datasets generated and/or analysed during the current study are not publicly available due to privacy considerations but are available from the corresponding author upon reasonable request.
References
Keung EZ, Lazar AJ, Torres KE et al (2018) Phase II study of neoadjuvant checkpoint blockade in patients with surgically resectable undifferentiated pleomorphic sarcoma and dedifferentiated liposarcoma. BMC Cancer 18:913. https://doi.org/10.1186/s12885-018-4829-0
Payne CE, Hofer SOP, Zhong T et al (2013) Functional outcome following upper limb soft tissue sarcoma resection with flap reconstruction. J Plast Reconstr Aesthet Surg 66:601–607. https://doi.org/10.1016/j.bjps.2013.01.034
López JF, Hietanen KE, Kaartinen IS et al (2015) Primary flap reconstruction of tissue defects after sarcoma surgery enables curative treatment with acceptable functional results: a 7-year review. BMC Surg 15:71. https://doi.org/10.1186/s12893-015-0060-y
Hussain ON, Sabbagh MD, Carlsen BT (2020) Complex microsurgical reconstruction after tumor resection in the trunk and extremities. Clin Plast Surg 47:547–559. https://doi.org/10.1016/j.cps.2020.06.007
Manfrini M, Bindiganavile S, Say F et al (2017) Is there benefit to free over pedicled vascularized grafts in augmenting tibial intercalary allograft constructs? Clin Orthop Relat Res 475:1322–1337. https://doi.org/10.1007/s11999-016-5196-2
Tanaka K, Ozaki T (2019) New TNM classification (AJCC eighth edition) of bone and soft tissue sarcomas: JCOG bone and soft tissue tumor study group. Jpn J Clin Oncol 49:103–107. https://doi.org/10.1093/jjco/hyy157
Tunn PU, Kettelhack C, Dürr HR (2009) Standardized approach to the treatment of adult soft tissue sarcoma of the extremities. Recent Results Cancer Res 179:211–228. https://doi.org/10.1007/978-3-540-77960-5_13
Wittekind C, Compton CC, Greene FL, Sobin LH (2002) TNM residual tumor classification revisited. Cancer 94:2511–2516. https://doi.org/10.1002/cncr.10492
Fujiwara T, Stevenson J, Parry M et al (2020) What is an adequate margin for infiltrative soft-tissue sarcomas? Eur J Surg Oncol 46:277–281. https://doi.org/10.1016/j.ejso.2019.10.005
Fujiwara T, Sumathi V, Parry M et al (2020) The role of surgical margin quality in myxofibrosarcoma and undifferentiated pleomorphic sarcoma. Eur J Surg Oncol. https://doi.org/10.1016/j.ejso.2020.11.144
Iwata S, Araki A, Funatsu H et al (2018) Optimal surgical margin for infiltrative soft tissue sarcomas: assessing the efficacy of excising beyond the infiltration. J Surg Oncol 118:525–531. https://doi.org/10.1002/jso.25165
Kapoor T, Banuelos J, Adabi K et al (2018) Analysis of clinical outcomes of upper and lower extremity reconstructions in patients with soft-tissue sarcoma. J Surg Oncol 118:614–620. https://doi.org/10.1002/jso.25201
Pinsolle V, Reau AF, Pelissier P et al (2006) Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg JPRAS 59:912–917. https://doi.org/10.1016/j.bjps.2005.11.037
Saint-Cyr M, Wong C, Buchel EW et al (2012) Free tissue transfers and replantation. Plast Reconstr Surg 130:858e–878e. https://doi.org/10.1097/PRS.0b013e31826da2b7
Saba SC, Shaterian A, Tokin C et al (2012) The pedicled myocutaneous flap as a choice reconstructive technique for immediate adjuvant brachytherapy in sarcoma treatment. Curr Oncol 19:e491–e495. https://doi.org/10.3747/co.19.1141
Sugg KB, Schaub TA, Concannon MJ et al (2015) The reverse superficial Sural artery flap revisited for complex lower extremity and foot reconstruction. Plast Reconstr Surg Glob Open 3:e519. https://doi.org/10.1097/GOX.0000000000000500
Ring A, Kirchhoff P, Goertz O et al (2016) Reconstruction of soft-tissue defects at the foot and ankle after oncological resection. Front Surg 3:15. https://doi.org/10.3389/fsurg.2016.00015
Hanasono MM, Skoracki RJ, Yu P (2010) A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg 125:209–214. https://doi.org/10.1097/PRS.0b013e3181c495ed
Sambri A, Bianchi G, Righi A et al (2016) Surgical margins do not affect prognosis in high grade myxofibrosarcoma. Eur J Surg Oncol 42:1042–1048. https://doi.org/10.1016/j.ejso.2016.05.015
Slump J, Hofer SOP, Ferguson PC et al (2018) Flap reconstruction does not increase complication rates following surgical resection of extremity soft tissue sarcoma. Eur J Surg Oncol 44:251–259. https://doi.org/10.1016/j.ejso.2017.11.015
Kang S, Han I, Kim S et al (2014) Outcomes after flap reconstruction for extremity soft tissue sarcoma: a case-control study using propensity score analysis. Eur J Surg Oncol 40:1101–1108. https://doi.org/10.1016/j.ejso.2014.05.004
Acknowledgements
The authors thank all of their patients and their families.
Funding
The authors did not receive support from any organisation for the submitted work.
Author information
Authors and Affiliations
Contributions
HH and ST designed the study, analysed the data, and wrote the manuscript. KH, TS, and YT were involved in the care of the patients included in this study and integrated the study. LF, CE, SS, and AFM designed the study and revised the manuscript. All authors have read and approved the final manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no relevant financial or nonfinancial interests to disclose.
Ethical approval
All procedures performed in studies involving human participants were as per the ethical standards of the institutional and/or national research committee and in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The independent ethics committee of the authors’ institution approved this study.
Informed consent
The need for informed consent was waived.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Hasegawa, H., Tsukamoto, S., Honoki, K. et al. Soft-tissue reconstruction after soft-tissue sarcoma resection: the clinical outcomes of 24 patients. Eur J Orthop Surg Traumatol 32, 1–10 (2022). https://doi.org/10.1007/s00590-021-02901-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00590-021-02901-9