Soft Tissue Sarcomas of the Hand: Functional Reconstruction and Outcome Analysis

Functional hand reconstruction following treatment of soft tissue sarcomas (STS) is a difficult surgical problem. Because survival rates between amputation and limb salvage do not differ, there is a trend toward reconstruction. Unlike amputation, hand salvage usually requires multiple complex operations in combination with adjuvant radiation or chemotherapy, prolonged rehabilitation, and carries a high complication rate. We investigated tumor recurrence, survival, and scored functional outcomes to determine if limb salvage is justified after hand STS resection. Patients treated for hand STS between years 1985 and 2005 were reviewed by two surgeons in three medical centers. All patients having functional reconstruction instead of amputation were reviewed. Patient demographics, tumor type and grade, resection extent, reconstruction procedure, timing, adjuvant therapy use, complications, tumor recurrence, survival, and functional outcome were recorded and analyzed. Five patients underwent functional reconstruction for hand STS. All patients underwent attempted curative resections, and four patients received neoadjuvant or postoperative radiation therapy. Three patients received adjuvant chemotherapy. Reconstructive techniques included three modified pollicizations, one free-tissue transfer, and one groin flap. All patients were alive and disease-free at a mean follow-up of 5 years (range 1.5-17 years). Three patients (60%) had local complications, requiring secondary surgeries. Two complications were related to radiation therapy. Hand function was evaluated using the Enneking Scoring System, and ranged from 17 to 28. The average Enneking score was 22.4, representing an average preservation of 74.6% of function. Because most patients retain excellent function and survival is unaffected, we advocate functional reconstruction despite high complication rates.     

Preoperative Isolated Limb Infusion of Doxorubicin and External Irradiation for Limb-Threatening Soft Tissue Sarcomas

Background At present, limb-sparing surgery is the most appropriate and acceptable treatment option for soft tissue sarcomas of the extremities. To increase the number of limb-sparing resections in the treatment of locally advanced soft tissue sarcomas of the extremities, preoperative radiotherapy and/or chemotherapy are often used. Isolated limb perfusion of cytostatic agents is an effective alternative option but technically complex. Isolated limb infusion, essentially a low-flow isolated limb perfusion without oxygenation via a percutaneous catheter, had been developed as a simple alternative. Objective The objective of this study was to achieve limb-sparing surgery in patients with locally advanced soft tissue sarcomas of the extremities that would otherwise have required an amputation or a functionally mutilating surgery by performing preoperative isolated limb infusion with doxorubicin and external beam irradiation to obtain local control and make limb-sparing surgery feasible. Methods A total of 40 patients with locally advanced soft tissue sarcomas of the extremities were evaluated between 2002 and 2005. Tumors were located in the lower limb in 28 patients (70%) and in the upper limb in 12 patients (30%). All of these patients were felt to be unresectable and were referred because amputation was considered the only available treatment option. They underwent preoperative isolated limb infusion with doxorubicin (0.7 and 1.4 mg/kg for the upper and lower limbs, respectively). Preoperative external beam radiotherapy started within 3–7 days after isolated limb infusion was administered. The total dose was 35 Gy in ten fractions. After 3–7 weeks, surgery was performed aiming at limb preservation. Results Tumor response was seen in 85% of patients, rendering these large sarcomas resectable in most cases. The mean values of pretreatment tumor volume and post-treatment volume were 2797 cm³ and 1781 cm³, respectively, with a significant p value of 0.0001. Histologic response was seen in 80% of patients. At a median followup of 15 months (range = 5–35), limb salvage was achieved in 82.5%. Procedure-related complications were limited and easily managed. Conclusion Isolated limb infusion with doxorubicin is a simple and safe method of regional chemotherapy. The addition of preoperative external beam irradiation helped to increase the rate of limb salvage in patients with large and/or high-grade soft tissue sarcomas of the extremities.     

小腿内侧皮瓣在修复口底癌术后缺损中的应用

目的 研究小腿内侧皮瓣在口底癌术后缺损修复中的应用.方法 应用该修复方法,共进行了5例口底癌术后缺损的修复,并对该皮瓣的应用解剖,制作技术及其优缺点进行了讨论.结果 7侧小腿内侧皮瓣均获得成功.口内外伤口均愈合良好,取得了良好的修复效果.覆盖于小腿内侧皮肤缺损区的皮片全部成活.结论 小腿内侧皮瓣适用于口底癌术后组织缺损的修复.对于口腔颌面部肿瘤术后的软组织缺损可利用携带部分比目鱼肌的小腿内侧皮瓣修复软组织缺损.小腿内侧游离皮瓣的皮下脂肪薄,皮瓣较柔软且远离术区,术后供区隐蔽,损伤小.     

The Surgical and Functional Outcome of Limb-Salvage Surgery With Vascular Reconstruction for Soft Tissue Sarcoma of the Extremity

Background This study compared the surgical, oncological, and functional outcomes of patients undergoing limb-salvage surgery for extremity soft tissue sarcoma with vascular resection and reconstruction with the outcomes of those undergoing limb-salvage without vascular reconstruction. Methods Nineteen patients were identified from a prospective soft-tissue sarcoma database who underwent vascular resection and reconstruction as part of their limb-salvage surgery and who were followed up for at least 1 year or until death. Each of these 19 patients was case-matched to 2 additional patients on the basis of tumor location, size, and depth; patient age; and timing of radiation. To compare functional outcome, a subset of patients was case-matched with additional criteria including wound-complication status, motor nerve sacrifice, similar preoperative function as determined by the Toronto Extremity Salvage Score, and no metastases at diagnosis or the 1-year follow-up. Results Patients in the vascular reconstruction group were more likely to require a muscle transfer (53% vs. 18%; P = .008), experience a wound complication (68% vs. 32%; P = .03), experience deep venous thrombosis (26% vs. 0; P = .003), experience significant limb edema (87% vs. 20%; P = .001), and ultimately require an amputation (16% vs. 3%; P = .07). Patients who underwent vascular reconstruction had only slightly lower Toronto Extremity Salvage Score scores 1 year after surgery (78.5 vs. 84.2; P = .35). There were no significant differences in local or systemic tumor relapse between the two groups. Conclusions Vascular reconstruction is a feasible option in limb-salvage surgery for soft tissue sarcoma but is associated with an increased risk for postoperative complications, including amputation. Although function is not significantly worse after vascular reconstruction, the results are less predictable.     

Functional Evaluation After Reconstruction With Myocutaneous and Fasciocutaneous Flaps for Conservative Oncological Surgery of the Extremities

Background Limb-preservation surgery has evolved during the last two decades through application of pedicled and free flaps and has obtained oncological results similar to those with amputation for malignant neoplasms of the extremities. However, functional evaluation has not been performed comprehensively after these advanced reconstructive procedures. The aim of this study was to describe the oncological, surgical, and functional outcomes achieved in these patients. Methods Patients had malignant neoplasms of the extremities and/or shoulder and hip girdle, underwent resective surgery and reconstruction with limb-preservation purposes, and were treated from 1997 to 2002. Survival analysis was performed, and functional evaluation after resection was performed with the Enneking system 1 year after surgery. Results Thirty-two patients were included. The mean overall survival of the cohort was 5.6 years. Functional evaluation mean rating percentages for the upper and lower extremities were 86.5% and 75.2%. Functional outcomes were better for reconstruction with free flaps than with pedicled flaps in the lower extremities (rating percentages, 67% and 79.6%, respectively; P = .018). Conclusions Limb-preservation surgery is a safe treatment for malignant neoplasms. It can be performed with low morbidity and good oncological outcomes. Functional results in our series were good. Lower limb preservation has superior scores with free flap reconstructions because of their potential to cover extensive defects, and better results were obtained in walking, gait, and weight bearing.     

带跟腱的腓肠肌内侧头肌皮瓣修复膝前软组织与髌腱缺损

目的：探讨膝部皮肤软组织髌腱缺损的修复方法。方法：利用带跟腱的排肠肌内侧头肌皮瓣移位进行修复，其中跟腱重建髌腱，肌皮瓣覆盖皮肤软组织缺损。临床应用13例（14肢）。结果：平均随访48．4月,样节活动正常。除1例膝部功能轻度受限外（原发损伤广泛合并复杂骨折），余功能基本正常。结论：该方法治疗此类损伤符合生理要求，且重建修复手术一次完成。     

Management of Great Vessels and Nerves in Limb‐Salvage Surgery for Bone and Soft Tissue Tumors

In recent years, limb‐salvage surgery has gradually replaced amputations and become one of the main treatment strategies for patients with bone and soft tissue tumors of the extremities. The goals of tumor resection in limb‐salvage surgery are to reduce the recurrence rate and preserve as much limb function as possible. However, depending on the size and specific location of the tumor, large neurovascular bundles may be involved. In addition, management of large nerves and vessels can make wide marginal resection more difficult. Sites where these problems commonly arise include the sciatic and tibial common peroneal nerve, artery and vein in the lower limbs.     

腓肠神经营养血管筋膜蒂皮瓣修复跟骨骨折外侧入路术后软组织缺损

目的探讨腓肠神经营养血管筋膜蒂皮瓣治疗跟骨骨折外侧人路术后软组织缺损的临床疗效。方法2011年1月至2012年5月,采用腓肠神经营养血管筋膜蒂皮瓣修复38例跟骨骨折外侧入路术后软组织缺损患者。腓肠神经与足背外侧皮神经相吻合重建皮瓣的感觉功能。结果所有患者皮瓣均完全成活．受区创口以及皮瓣供区切口均I期愈合,无1例患者出现术后血管危象。经6～18个月随访,皮瓣质地柔软、弹性好,无臃肿,外形满意,皮瓣两点辨别觉6．5-11mm。结论本方法操作简便、血运可靠,术后外观及功能恢复满意,值得临床推广应用。