Functional Reconstruction of Sarcoma Defects Utilising Innervated Free Flaps

Soft-tissue reconstruction following preoperative radiotherapy and wide resection of soft tissue sarcoma remains a challenge. Pedicled and free tissue transfers are an essential part of limb sparing surgery. We report 22 cases of sarcoma treated with radiotherapy and wide excision followed by one-stage innervated free or pedicled musculocutaneous flap transfers. The resection involved the upper limb in 3 cases, the lower limb in 17, and the abdominal wall in 2. The flaps used for the reconstruction were mainly latissimus dorsi and gracilis. The range of motion was restored fully in 14 patients. The muscle strength of the compartment reconstructed was of grades 4 and 5 in all patients except one. The overall function was excellent in all the cases with functional scores of 71.2% in the upper limb and 84% in the lower limb. The only 2 major complications were flap necrosis, both revised with another flap, one of which was innervated with restoration of function. Innervated flaps are valuable alternatives for reconstruction after sarcoma resection in the extremity and in the abdominal wall. The excellent functional results are encouraging, and we believe that innervated muscle reconstruction should be encouraged in the treatment of sarcoma after radiotherapy and wide resection. 1. Introduction In the mid-1970s the rate of amputation for extremity soft tissue sarcomas was 40–50% [1]. During this period, radiation therapy (RT) was considered a palliative rather than curative modality for the large tumour masses [2]. A decade later, however, Rosenberg and colleagues reported that when compared with amputation, wide excision with external beam RT was associated with equivalent 5-year disease-free and overall survival [3]. Since then, the combination of surgery and RT has been proven to yield superior local control of tumour compared to local excision alone and has been fundamental to the adoption of limb-sparing surgery for high-risk extremity STS [4–7]. Preoperative RT is preferred at our Institute because of smaller RT targets [8, 9]. lower RT dose due to better limb perfusion and oxygenation, [6, 10]. and decreased late toxicity [11] compared with postoperative RT despite a slighter higher rate of wound complications. Surgical margins are the most important factor associated with local tumour control [12]. In many cases, obtaining good oncologic margins can result in extensive or critical loss of muscle/tendon units. Not only are the reconstructions required after such resections likely to be challenging, wound healing difficulties in the postoperative