The 2004 Annual Meeting (January 14-20, 2004) of OASYS_NEW

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Limb Sparing Surgery for Upper Extremity Sarcomas

Deune EG1, Tufaro AP1, Frassica D2, and Frassica F3. (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 Orthopedics, Johns Hopkins School of Medicine, 601 N. Caroline St, Baltimore, MD, USA

Of the 8300 annual cases of soft tissue sarcomas, 50% are in the extremities with one-third in the upper extremities. Unlike the lower extremity, dexterity is an important component of upper extremity function. This makes upper extremity reconstruction more challenging, as functional restoration may be required.

Between February 1998 and May 2003 (64 months), 93 patients underwent limb-sparing surgery and soft tissue coverage for extremity sarcomas. 28 patients (M=17,F=11,age:54.1±20.2) underwent sarcoma resection for 29 upper extremities requiring 30 flaps (free 11, pedicle 19) for reconstruction (1 delayed). MFH was the most common (n=14, 50%). 82% of the tumors were high grade. 9(31%) of the tumors were in the forearm. 12(41%) were in the upper arm (humerus region). Four flaps were used: latissimus: 16(53%), rectus abdominis: 4(13.3%), gracilis: 2(6.7%), fasciocutaneous: 8(26.7%). 9 patients had functional restoration surgery to restore crucial function. 4 required tendon grafts or transfers to restore wrist or finger functions. 5 had innervated flaps for elbow flexion (latissimus=2, gracilis=2) and elbow extension (latissimus=1). One free flap failed (91% success). All 23 pedicle flaps survived. (total flap survival: 96.7%) Resection took 3.5±1.7 hrs and reconstructive took 4.9±2.2 hrs, (pedicle flaps: 3.6±1.7 hrs; free flaps: 6.6±1.3 hrs). 25(89%) patients had adjuvant therapy. 57% had postoperative complications (32% wound; 21% non-wound).

Follow-up has been 19.7±13.9 mons (range: 1-42 months). One person was lost to follow-up. One had preoperative metastasis. 6 developed postoperative metastases. (most common: lung). Three had local recurrences. No limbs have been amputated. 3 have died: 2 from metastasis, one from an accident. (survival: 21.3±12.2 mon).

Postoperative functionality was assessed using the Toronto Extremity Salvage Score, a self-administered survey, in patients who were at least 6 months postop. 12 of these 18 patients (67%) complete the survey. Their TESS score was 0.8, indicating only slight disability in their daily activities (1 = no difficulty, 0.75 = slight difficulty). Their self-rated disability score was 4.4 (no disability=5, slight=4). Of the 13 who were preoperatively employed, 9(69%) have returned to their preoperative occupation without restrictions.

Limb salvage is now the preferred surgical modality in management of extremity sarcomas. Functional restoration surgery is a crucial element in attaining a successful outcome. Despite a moderate rate in minor wound complications, no upper limbs have been amputated. These patients did well and reported only limited functional disability. This would have been quite different in patients with upper extremity amputations.


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