Microsurgical Preservation of Ambulation in Lower Extremity Sarcoma Treatment

Purpose: Lower extremity sarcoma treatment has evolved from primarily amputation procedures towards limb salvage when possible to preserve ambulation. Sarcoma resections frequently result in massive defects which usually require microsurgical reconstruction. Until now success has been defined mainly as achieving flap survival in the hostile conditions of a radiated surgical field. This series demonstrates that not only can massive tissue defects be reliably reconstructed with preservation of ambulation, but that immediate functional reconstructions can be successful at restoring ambulation, potentially expanding the indications for limb salvage procedures.

Methods: A 5 year retrospective review of all microsurgical reconstructions for limb salvage in lower extremity sarcoma patients was completd at our institution. Patients were additionally asked to complete the Toronto Extremity Salvage Score (TESS) quality of life surveys.

Results: Over a five year period, 22 patients (average age 52.2 years) underwent free flap reconstructions for 23 sarcomas with an average follow-up of 14 months. 85% of patients underwent neoadjuvant radiation therapy. The thigh was the most common tumour site (56.5%) and 3 named muscles were resected on average. Perforator flaps were used in the majority of reconstructions (68.18%), and functional muscle transfers or immediate tendon transfers were used in three patients. There were no flap take-backs or failures, and all patients achieved ambulation. Two patients in the series died, each from metastatic disease and not local recurrence. Rates of fat necrosis and secondary lymphedema occurred at 13.6% and 9.1%, respectively. A 50% response rate was achieved for the TESS survey, with an average score of 83.79. Lowest average TESS scores were associated with kneeling, sporting activity participation, and rising from kneeling. There were no correlations with TESS scores and patient age, tumor locations, resection surface area or number of muscles resected.

Conclusions: Microsurgical reconstruction of lower extremity sarcoma defects enables patients to resume ambulation. The treatment model is now beyond achieving success in a radiated tissue bed.  Both preservation and restoration of function utilizing functional microsurgical reconstructions should now be considered safe and effective in lower extremity sarcoma limb salvage.