UMDNJ - New Jersey Medical School, Newark, NJ, USA.
PURPOSE: Limited studies have shown limb-sparing resection of tumors can salvage functional extremities at the cost of greater incidences of minor complications. We analyzed a large number of patients operated on by our institution's musculoskeletal oncology team to determine if this complication rate could be reduced by a multidisciplinary team including the plastic surgeons.
METHODS: A retrospective evaluation of 102 muscle flap reconstructions in 76 patients was performed using office and hospital records. Variables considered included tumor type, grade, and location, as well as type of osseous reconstruction, flap source, pedicled vs. free flaps, and whether patients recieved chemotherapy and radiation pre- or post-operatively. Outcomes included operative time, blood loss, rates of major and minor complications, oncologic recurrences, MSTS functional scores, and long-term survival rates.
RESULTS: A total of 76 patients underwent major reconstruction after radical excision of musculoskeletal tumors. The mean age was 39.1 years (4-90 yrs). There were 79 pedicled flaps and 23 free flaps. Seventy-eight flaps from five donor sites accounted for 76.5% of the reconstructions: the medial gastrocnemius (n=28), lateral gastrocnemius (n=27), latissimus dorsi (n=10), rectus abdominus (n=9), and lateral arm (n=4). Twenty-one patients underwent microvascular fre tissue transfers consisting of: latissimus dorsi (n=9), radial forearm (n=7), and rectus abdominis (n=5).
Oncologic management consisted of excision alone (27 patients, 35.5%), while 28 patients (37%) received adjuvant therapy (preop=22, postop=4, both=2). Sixteen patients underwent radiation treatment, (preop=7, postop=9). Minor complications occurred in 15 patients (19.7%) including wound necroses, seromas, postop bleeding, postop infections, and DVT. There were three major complications (3.9%): two patients with flap loss and one patient with a nonfatal PE. Five patients required revision with a second flap, and two required and additional skin graft. The overall flap survival rate was 98%. Three patients had local recurrences. One patient was treated with excision of the recurrent tumor and a microvascular free rectus flap, and the other two patients were treated with amputation of the affected limb. Since the study began, 16 patients (21.1%) have died of their disease. Five patients are alive and stable with metastases. Sixty patients are currently alive and functioning well as a result of combined therapy. In 54 patients for whom MSTS functional evaluation scores were calculated, the mean was 27.1 (range 12-30).
CONCLUSION: This study represents a large experience of limb salvage procedures involving musculoskeletal oncology and plastic surgery services. Our survival rates of 78.9% and limb salvage rates of 97.4% are consistent with previously reported studies. However, the rates of both local recurrence and of minor complications are lower than those reported elsewhere. Several factors may be responsible for this lower incidence of wound complications. The involvement of the plastic surgery service and advances in soft-tissue reconstruction of extremity defects are likely to play a major role. An aggressive team approach to musculoskeletal tumors can effectively treat musculoskeletal tumors and salvage functional extremities. Plastic surgery has an important role in a combined musculoskeletal oncology service and may help reduce the major morbidity of limb-sparing surgery, wound complications.