Advances in the management of soft-tissue and bone sarcomas—referred to collectively as “musculoskeletal sarcomas” hereafter—have resulted in significant improvements in survival and quality of life. 1–3 Several factors have likely contributed to these advances, including improved surgical technique and the development of referral centers for sarcoma treatment that have embraced a multidisciplinary approach. 1,2
The goal of treatment for musculoskeletal sarcomas is to optimize oncologic outcome and maximize functional restoration. 2,3 Surgical resection has been the mainstay of therapy, 1–7 as detailed earlier in this supplement. In patients with musculoskeletal sarcomas of the extremities, limb-sparing resection has been shown to be significantly superior to amputation. 1,7–9 Wide local excision of the tumor along with its muscle compartment, followed by adjuvant chemotherapy and radiation therapy, has allowed limb salvage without an increased risk of recurrence in many patients. 3 However, wide tumor resection can leave large defects that are not amenable to coverage by mobilization of the surrounding tissues, particularly if those tissues have been irradiated. As a result, resection can expose neurovascular structures, bone without periosteum, alloplastic materials, and internal fixation devices.
GOALS OF RECONSTRUCTION
Reconstructive surgery after musculoskeletal sarcoma resection aims to provide adequate wound coverage, preserve function, and optimize the cosmetic outcome. 1–3 Tumors can be found on areas crucial to limb movement or may involve tissues vital to limb function. Reconstruction to repair these deficits can take many forms. In certain situations, amputation is still inevitable. In those cases, the reconstruction should provide stable stump coverage with durability and the ability to fit well with an external prosthesis. 3
TIMING OF RECONSTRUCTION
Immediate reconstruction should be pursued if possible
Immediate reconstruction after a negative margin should always be considered and should be attempted when possible. Immediate reconstruction allows the reconstructive surgeon to benefit from better evaluation of the defect and exposed structures, as no scar tissue is present to distort the anatomy. Likewise, patients benefit from faster recovery and can receive adjuvant treatment (if necessary) sooner, as well as earlier rehabilitation. Patients may also benefit psychologically from immediate reconstruction. 1,3
Indications for delayed reconstruction
Delayed reconstruction is primarily indicated when there are wound healing problems or there is uncertainty about the tumor margins. Secondary indications for delayed reconstruction are wound dehiscence and unstable soft-tissue coverage. If hardware is exposed, the recommendation is for early intervention and wound coverage with well-vascularized tissue to protect and cover the implant or prosthesis.
What about radiation therapy?
A very important consideration in reconstruction is the need for neoadjuvant or adjuvant radiation therapy. 3,10,11 Irradiated wounds have a higher incidence of complications, including a tendency to dehisce. In patients who have been previously irradiated, the best practice is to perform immediate reconstruction with well-vascularized tissue, most likely a free tissue transfer. 4,6,11,12 This practice reduces hospital stay, costs, and morbidity and increases limb salvage and patient satisfaction. 13
SYSTEMATIC PREOPERATIVE PLANNING NEEDED
Reconstruction after musculoskeletal sarcoma resection should be planned systematically within a process that involves preoperative anticipation of the defect size and the resulting functional and cosmetic deficits that might need to be addressed. A preoperative visit to the reconstructive surgeon can be very helpful for presurgical planning.