Musculoskeletal Stability and Function after Oncologic Resection: More Than Just Coverage

Introduction: En-block resections in extremity oncology frequently disrupt functional musculoskeletal units.  To mitigate disability, pre-operative and intra-operative “orthoplastic” collaborative approach identified functional, often composite and/or synergistic flaps to restore stability and function while providing traditional soft-tissue coverage and/or fill frequently in the setting of pre-operative (Preop-XRT) or post-operative radiation (Postop-XRT).  We review our experience using this approach in tumor extirpative surgery.

Methods: Patients who underwent upper or lower extremity tumor ablation by a single orthopedic surgeon and subsequent reconstruction by a single plastic surgeon from 2012-2015 were identified. Patient demographics, tumor pathology, operative details, and functional outcomes were examined.

Results: 8 patients underwent tumor extirpation followed by 9 functional flap transfers to restore stability of the shoulder (deltoid sarcoma/Postop-XRT, scapula osteosarcoma, scapula Ewing sarcoma), hip (femoral head chondrosarcoma, gluteal sarcoma/Postop-XRT), knee (liposarcoma/Postop-XRT, giant cell/Preop-XRT), and ankle (giant cell/Preop-XRT, peroneal sarcoma/Postop-XRT).  Respective reconstructions were: shoulder stability/function achieved with scapula fascia, serratus anterior, and distal trapezius flaps.  hip stability/function achieved with inferior gluteal/iliotibial band flap to femoral head prosthetic, and anterolateral thigh/tensor fascia lata/ieotibial band flap to remnant gluteus maximus; knee stability/function achieved with gracilis flap (femoral re-neurotization) to patella tendon, and composite flexor hallucis longus flap with tendon to reconstruct lateral collateral ligament with distal fibula flap to proximal fibula defect; ankle stability/function achieved with gastrocnemius flap to peroneus longus/brevis, and soleus flap to peroneus longus/brevis.  Average defect size 130±112cm²; all resulted in either loss of musculoskeletal stability on intraoperative stress testing and/or resection of functional muscle units. Mean age 33.9±18.9 years with follow-up 22±9.8 months (range 10-35 months). 3/3 shoulder cases achieved full/symmetric range of motion. 5/5 lower extremity patients were able to ambulate postoperatively (1 required assistive device). Postoperative mean MSTS scores were excellent: 25.4±5.5/30.  Complications included pulmonary embolus (n=1), and delayed wound healing (n=1, non-XRT patient). 4/8 patients had disease recurrence, 1 died of disease.

Conclusions: Our cohort demonstrated stable wound coverage despite large oncologic resections.  Moreover, “orthoplastic” planning, wherein a multidisciplinary team identifies and addresses anticipated functional consequences of tumor extirpation, tailored reconstructions that exploited local muscle synergy and/or static requirements which resulted in reliable joint stability, range of motion, and even strength recovery.  We advocate this approach to mitigate disability while concurrently achieving traditional coverage/fill goals in single-stage reconstructions.