The 2003 Annual Meeting of OASYS_NEW

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Limb Reconstruction for Sarcomas Located in the Distal One-Third of Lower Extremities

Deune EG1, Tufaro A1, Frassica D2, and Frassica FJ3. (1) Division of Plastic Surgery, Johns Hopkins School of Medicine, 601 N. Caroline St, JHOC 8152B, Baltimore, MD, USA, (2) Dept of Radiation Oncology, Johns Hopkins School of Medicine, 10753 Falls Rd, Suite 145, Baltimore, MD, USA, (3) Dept of Orthopedic Surgery, Johns Hopkins School of Medicine, 601 N. Caroline St, Baltimore, MD, USA

50% of the 6000 new annual cases of soft tissue sarcomas occur in the extremities with a 2 to 1 ratio between the lower and the upper extremities. Those occurring in the distal one third of the lower extremity are more challenging to reconstruct because free flaps are required and functional restoration may be necessary.

Between February 1998 and May 2002 (51 months), 74 patients underwent limb-sparing surgery and immediate soft tissue coverage for sarcomas in our institution. 55 of those sarcomas were in the lower extremity with 9 in the distal third (leg and foot). 9 were male and 3 were female. Mean age was 45.9±21.9 yrs. The most common pathology was malignant fibrous histiocytoma (n=6, 67%) with 3 high-grade, 3 intermediate-grade, and 1 low-grade. 2 could not be graded. All coverage was done with free flaps (gracilis 7, rectus abdominis 2) 4 patients underwent simultaneous functional restoration surgery. 3 had autologous tendon grafts to restore ankle/toe extension and 1 underwent placement of an Achilles tendon allograft to restore plantar flexion.

The length of follow-up is 11.8±8.7 months (range 1 – 29 months). Of the 9 free flaps, 1 failed. 4 patients developed wound-healing complications (donor site hematoma, delayed skin graft healing, and pressure ulceration of the insensate flap). 7 patients had adjuvant therapy (2 preoperatively, 4 postoperatively, and 1 both preoperatively and postoperatively). No patients have developed either metastasis or local recurrence, and no limbs have had to be amputated. Postoperative function was rated excellent, good, or poor. 5 (71%) had excellent function returning to preoperative activities, and 2 (29%) report having moderate function with restrictions of preoperative activities. None report poor function. 2 patients were retired and one was disabled preoperatively. Of the 5 gainfully employed preoperatively, all 5 have gone back to their previous employment without limitations.

Limb salvage has now become the standard of care in the surgical management of limb sarcomas. The distal third provides an addition challenge because of the need to restore function as well as coverage. Similar to the experience with traumatic wound coverage, defects in the distal third lower extremity requires free flaps for coverage. Our results show that aggressive management of sarcomas followed by soft tissue coverage along with functional restoration surgery when required, provides excellent results.


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