- 1 What are the factors that impact on the choice of reconstructive options in BSTTs?
- 2 Evidence summary and recommendations
- 3 Issues requiring more clinical research study
- 4 References
- 5 Appendices
- 6 Further resources
What are the factors that impact on the choice of reconstructive options in BSTTs?
Reconstructive surgery in the management of sarcoma is a broad and varied field and the reconstructive surgeon is an integral member of the multidisciplinary team.
The first priority is oncological resection of sarcoma with sufficient margins. Reconstruction aims to return optimal function and appearance to the affected area. When this involves the limb, the preference is for reconstruction (termed limb salvage surgery) though occasionally removal of part or all of the limb may be required (termed limb ablative surgery).
During oncological resection, preservation of functionally critical neurovascular structures is desired (e.g. common femoral artery, sciatic nerve in lower limb). Where preservation of critical structures is not possible, consideration is given to reconstruction of these elements (e.g. reconstructing arterial conduit). Where reconstruction is not possible, this may necessitate a limb ablative surgical approach (e.g. amputation).
When it is possible to preserve or reconstruct critical neurovascular structures, reconstruction focuses on:
- Soft tissue covering
- Functional transfer for absent muscles, nerves
Bony reconstruction can be:
- No formal reconstruction
- Alloplastic reconstruction
- Non-vascularised autologous reconstruction
- Vascularised autologous reconstruction
- Extracorporeal irradiated autologous reconstruction
- Cadaveric bone reconstruction
Bony resection has added considerations of proximity to critical skeletal elements - especially joints and joint stabilising structures, as well as the physis (growth plate) in the skeletally immature. Involvement of these structures necessitates more major excision and thus reconstruction.
When dealing with younger individuals skeletal growth is an added consideration, but secondary to safe oncological clearance. Due to the adaptability of the paediatric population however often more novel surgical procedures can be undertaken with the hope of true biological reconstruction. On occasion prosthetic reconstruction must be used however, and technology in this field is also advancing (e.g. "growing" prostheses, custom made prostheses), outcomes differ for different skeletal sites.
Soft tissue reconstruction incorporates replacement of:
- Skin/soft tissue cover
- Important neurovascular structures
- Muscle if critical for function
Factors affecting choice of soft tissue reconstruction:
- Patient factors
- -General health (age, body mass index (BMI), functional status, nutritional status)
- -Cardiovascular disease
- -Neurological disease
- Tumour pathology features
- Resection wound features
- -Bony reconstruction requirement
- -Exposed bone/tendon/alloplastic reconstruction
- Treatment related factors
- -Peri-operative chemotherapy
- -Peri-operative radiotherapy
General principles of reconstruction in sarcoma
General principles in keeping with management of reconstruction in all patients:
- Patient general optimisation
- -Minimise smoking
- -Diabetic control
- -General complication reduction (measures including DVT prophylaxis, chest physiotherapy, peri-operative antibiotics)
- Optimal resectional surgery (tumour clearance, minimal injury to critical reserved structures)
- Optimal bony reconstruction, where required
Effect of general factors on reconstructive options
There is a significant benefit to patient outcome with extremity soft tissue sarcoma if the patient is better educated, optimistic, with better baseline health-related quality of life. 
Management of lower limb sarcoma cases following unplanned (Whoops) primary procedure is more complex with greater resectional surgery and more complex reconstructive surgery required, often with vascularised tissue.
Specific principles of soft tissue reconstruction in sarcoma
Choice of reconstructive techniques
Due to the size and complexity of resectional defects for sarcomas, soft tissue coverage with vascularised soft tissue flaps should be considered in all cases, both in children and adults. This is supported by several studies showing improved functional outcome and lower wound complications when vascularised soft tissue coverage procedures, such as myocutaneous and fasciocutaneous flaps are used.  
Effects of radiotherapy on reconstructive options
Radiotherapy to area (in any form) reduces vascularity and impairs wound healing. Radiotherapy (particularly pre-operative radiotherapy) leads to a higher rate of complications (OR 2.67) than those not treated with radiotherapy, in extremity soft tissue sarcoma.
In the only randomised controlled study comparing complications of pre-operative and post-operative radiotherapy, pre-operative therapy was shown to reduce radiotherapy-related morbidity and increase surgical morbidity.  A well-designed retrospective case series review also confirmed these findings.  Another retrospective study with substantial biases and confounders, comparing post-operative and pre-operative radiotherapy in development of complications, suggested post-operative radiotherapy may lead to a higher rate of complications than pre-operative radiotherapy. (This last study was retrospective, with no case-control matching for factors affecting healing, tumour location and previous surgical intervention, and quite disparate groups when these factors were reviewed.) 
Vascularised soft tissue coverage (often with greater surgical complexity) is recommended in cases treated with pre-operative radiotherapy to reduce the risk of wound complications.  When pre-operative radiotherapy is used in treatment of sarcoma, vascularised tissue coverage has a lower complication profile in reconstruction of surgical defect compared to direct closure.  When wound complications occur after pre-operative radiotherapy and resection of extremity soft tissue sarcoma, vascularised soft tissue coverage is an effective management tool. 
Vascularised soft tissue coverage following resection of extremity soft tissue sarcomas tolerates post-operative radiotherapy with low wound complication rate (5%). 
Effects of chemotherapy on reconstructive options
Cytotoxic chemotherapy impairs wound healing. Timing of chemotherapy should be coordinated with planning of resectional and reconstructive surgery to minimise wound healing problems and infection risk (especially in the setting of major resections with prosthetic/allograft reconstruction).
Additional considerations in vascular reconstruction
When resection of extremity soft tissue sarcoma requires removal of major vascular supply to the limb, reconstruction of either the artery alone, or the artery and accompanying vein, have equivalent results. 
Additional considerations in nerve and muscle reconstruction
When significant nerve resection is required, consideration should be made for reconstruction of this with vascularised or non-vascularised nerve graft.
When substantial functional deficit results from muscle resection, consideration should be made to transpose other muscles to provide this function, or use free tissue transfer of vascularised, neurotised muscle to provide the absent function.
Reconstruction in specific sites
Head and Neck
- Undertake careful planning in this functionally and aesthetically sensitive area to:
- Reconstruct bony framework and contour, restore functional elements (as relevant, ocular cover if eye preserved, oral competence, facial nerve reconstruction, functional muscle reconstruction), soft tissue/skin cover.
- Due to the limited bulk of soft tissue and diminished laxity in the lower leg, soft tissue coverage of sarcoma defects in this area often requires free tissue transfer to provide vascularised soft tissue coverage. These techniques are safe and effective in this patient group. 
- Pedicled gastrocnemius flap is an useful technique to cover soft tissue defects of the knee and is clinically reliable and effective.  It is also a useful adjunct to extensor mechanism repair where either proximal tibial or patella tendon excision has been required.
- Due to limited soft tissue laxity in the upper limb area, particularly the forearm and hand, often free tissue transfer or regional flaps are required to provide vascularised soft tissue coverage for sarcoma defects. Free flaps are more often required in distal defects (e.g. hand, wrist), while pedicled flaps are used more often in proximal defects (e.g. shoulder) due to greater available options. These techniques are reliable and effective in the reconstruction of both bony and soft tissue defects. Pedicled and free flap reconstruction have equivalent good functional outcomes when required in upper limb sarcoma reconstruction    **add ref Payne
- Sarcomas of the forearm and hand are best managed by a specialist team to enable optimal reconstruction and functional outcome. 
- Pedicled latissimus dorsi flap is an useful technique to cover soft tissue defects of the shoulder and is clinically reliable and effective. 
- Reconstruct chest wall in layers. Polypropylene mesh with vascularised flap coverage has shown to be a functionally acceptable option in reconstruction of this area. Thoracoplastic techniques to utilise locoregional muscle flaps in reconstruction should also be considered preoperatively. 
Specific principles of bony reconstruction in sarcoma
Reconstruction in areas of the bone which are not in close proximity to joints (metadiaphyseal, diaphyseal location) is necessary to return structure and function to the limb. Bone reconstruction near to joints or with epiphyseal involvement is generally more complex. Available options vary relating to the location – in some areas, prosthetic joint replacement is a stable option with acceptable function and longevity, whereas in other locations options such as fusion may be preferred.
Function is the priority in bony reconstruction. This can be assessed by a number of measures. These measures focus on both location specific function (such as range of movement, stability, and level of discomfort) and also functional status in general activities (both psychological and physical). Tunn recommends that multiple measures of function and outcome are adviseable (eg MSTS, TESS, RNL, ISoLS). 
It is generally accepted that, where possible, limb salvage procedures result in better functional outcomes, but do not necessarily result in greater quality of life.         Robert examined long term outcomes of patients following limb salvage and limb ablation, and found that patients undergoing late amputation (due to failed limb salvage) fare worse psychologically due to greater difficulty with body image.
Reconstruction in metadiaphyseal areas
- A number of options are available with preference for a biological reconstruction where possible.
- Examples of autologous vascularised bone incude the vascularised fibula flap. This is a reliable and functionally effective technique to reconstruct bony defects following sarcoma resection. 
- Bone that has undergone extracorporeal irradiation has also been successfully used.  
- as has prosthetic (metallic) intercalary reconstruction.
- Sometimes combinations of the above are used.
Muscolo has shown acceptable outcomes with osteoarticular allograft, though Kim showed poor outcomes with osteoarticular autograft that had undergone extracorporeal irradiation.
The varied results and techniques available reflect differing experience and technical availability at different centres, but it is accepted that this highly specialised surgery is performed at centres with particular expertise in sarcoma surgery.
Reconstruction in specific joint locations
Reconstruction of specific joint areas should be tailored to the needs of the individual patient. Priority is given to ensure maintenance of neurovascular structures crossing joints to provide distal function, and muscle groups acting on the joint are also preserved or reconstructed. Preferred options for managing specific joint locations follows:
- Hand – distal amputation with no, or delayed reconstruction in digits. Resection of affected area and reconstruction with bony support in proximal hand.
- Wrist – fusion is preferred management at this site.
- Elbow - use of prosthesis.
- Shoulder – use of prosthesis or resection (arthrectomy).
- Foot - amputations tailored to specific site.
- Ankle fusion is preferred management at this site.
- Knee - use of prosthesis.
- Hip - use of prosthesis.
- Many reconstructive options are available in the pelvis due to the complexity of the anatomy and size. In general principles, survival outcomes are improved with wide/radical resection in this area but complication rates of reconstruction are often high.
- Unique anatomy again determines resectability whilst maintaining spinal cord function, but where possible total or subtotal vertebrectomy can be performed with various stabilisation options, including combination cage and plating anteriorly with instrumented pedicle fixation posteriorly.
Reconstruction in the growing skeleton
Evidence summary and recommendations
|Improved patient outcome with extremity soft tissue sarcoma if patient is better educated and optimistic.||III-3|||
|Provision of education and psychological support is an important component in holistic care of the sarcoma patient.||C|
|Unplanned primary surgery in the management of lower limb sarcomas requires more complex resection and reconstruction, often with vascularised tissue.||IV|||
|Sarcomas are better managed in a specialist sarcoma unit with planning of primary resection, reconstruction and timing of radiotherapy (where required) for optimal outcome.||D|
Surgical reconstruction options
|Vascularised tissue coverage is safe and effective in management of extremity soft tissue sarcomas requiring larger resections and post-operative radiotherapy.||III-2|||
|Vascularised tissue coverage with myocutaneous and fasciocutaneous flaps in extremity soft tissue sarcoma reconstruction is reliable and assists in limb preservation.||IV|||
|Vascularised soft tissue coverage is safe and effective in the management of sarcomas in childhood.||IV|||
|Consider vascularised tissue coverage in management of soft tissue sarcomas, particularly when large resections or radiotherapy expected, and in children.||C|
|Radiotherapy (particularly pre-operative radiotherapy) leads to a higher rate of complications than those not treated with radiotherapy (OR 2.67) in extremity soft tissue sarcomas.||III-2|||
|Pre-operative radiotherapy leads to a higher wound complication rate in comparison to post-operative radiotherapy.||II|||
|Post-operative radiotherapy may lead to a greater radiation-related complication profile in comparison to pre-operative radiotherapy in treatment of sarcoma.||III-2|||
|Recognise that pre-operative radiotherapy leads to a higher wound complication profile than (i) no radiotherapy, and (ii) post-operative radiotherapy.||B|
|Reconstruction of sarcoma defects treated with pre-operative radiotherapy is more effective when vascularised flap closure is used, particularly free tissue transfer.||III-2|||
|Pre-operative radiotherapy leads to a greater use of vascularised flap coverage of soft tissue sarcoma defects.||II|||
|Following pre-operative radiotherapy, reconstructive surgery with vascularised soft tissue coverage is often indicated to manage later wound complications in extremity soft tissue sarcoma.||IV|||
|Consider vascularised flap coverage (including free tissue transfer) in reconstruction of sarcoma defects following pre-operative radiotherapy.||B|
|Vascularised soft tissue coverage after resection of extremity soft tissue sarcomas is resilient when treated with post-operative radiotherapy, with low wound complication rate.||IV|||
|Consider vascularised flap coverage (including free tissue transfer) in reconstruction of sarcoma defects when post-operative radiotherapy is anticipated.||D|
Reconstruction of vascular defects
|When vascular resection is required in management of extremity sarcoma, reconstruction of artery alone, or artery and vein, have equivalent outcome.||IV|||
|When restoration of vascularity to a limb is required following sarcoma resection, prioritise arterial reconstruction and consider the need for venous reconstruction.||D|
|Free tissue transfer in reconstruction of lower limb soft tissue sarcoma defects is safe and effective.||IV|||
|Consider vascularised tissue in reconstruction of bone and soft tissue in lower extremity sarcoma.||D|
|Vascularised soft tissue coverage of soft tissue sarcoma defects in upper limb is reliable and effective, particularly in management of large tumours, recurrent disease and following pre-operative radiotherapy..||IV||, , |
|Vascularised fibular flap is a reliable and effective tool in reconstruction of bony sarcoma defects in the upper limb.||IV|||
|Consider vascularised tissue in reconstruction of bone and soft tissue in upper extremity sarcoma.||D|
Forearm and hand
|Reconstruction of sarcomas in forearm and hand is challenging and is best managed by a specialist team for best functional outcome.||IV|||
|Referral to specialist hand and upper limb surgical team to be sought when surgical resection and reconstruction is required for sarcoma in the hand and forearm area.||D|
|Reconstruction of chest wall sarcoma defects with mesh and vascularised regional flaps, including pectoralis major and latissimus dorsi muscles, are safe and effective.||III-2||, |
|Consider incorporation of thoracoplastic techniques with mesh and vascularised flap coverage in management of chest wall defects following sarcoma resection.||C|
|Reconstruction of skeletal elements is age, site, and tumour specific and requires specific knowledge and experience of surgical and adjuvant therapies, as there are wide ranging options available.||IV||, , , , , , , , , , , , , , , , , , , , , |
|The decisions for reconstruction of skeletal elements are ideally made at a specialist sarcoma unit.||D|
The nature of reconstruction of defects following sarcoma resection is often complex due to the required size of resection, likelihood of need for perioperative radiotherapy with associated surgical challenges, and variation in involved tissue types. Specialist Multidisciplinary Team management is advised for all cases for optimal outcome.
Optimisation of general patient factors, both physical (including diabetic control, nutrition, minimising smoking and avoiding preventable perioperative morbidity) and psychological, will provide benefits to patient outcome. Patient education regarding the disease process and treatment options is also important in achieving the best holistic outcome.
Radiotherapy (in any form) reduces vascularity and impairs wound healing. Reconstructive options are affected by choice and timing of radiotherapy. A treatment plan for each case should be discussed at commencement of treatment to determine best timing and choice of surgical resection, surgical reconstruction and radiotherapy. This will allow best outcome with minimisation of surgical-related and radiotherapy-related morbidity.
When limb-preserving surgery is undertaken, care should be taken to reconstruct all resected tissues. This includes skeletal stability in bony reconstruction, reconstruction of neurovascular structures and functional muscle groups, and overlying soft tissue coverage.
In all resection defects requiring soft tissue coverage, vascularised tissue is the preferred reconstruction. This may be in the form of locoregional flap transfer, or free flap tissue transfer with reconstruction of the tissue vascularity using micro-surgical anastamoses of blood vessels. This enables best healing of underlying structures, reduces infection and other complication risks relating to skeletal implants, and provides greatest resilience to radiotherapy.
Restoration of function is the priority in reconstruction of the bony skeleton. Many options are available for reconstruction in metadiaphyseal areas, with preference for biological reconstruction where possible. Endoprosthetic reconstruction is commonly used in periarticular reconstruction.
Limb salvage procedures result in better functional outcomes, but do not necessarily result in greater quality of life.
Issues requiring more clinical research study
- Assessment of value of combined specialist multidisciplinary clinics in management of sarcomas.
- Multi-centre trials assessing specific reconstructions of anatomical locations.
- Multi-centre trials assessing timing of radiotherapy, relationship to reconstruction and long term function and quality of life outcomes.
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