Sarcomas are neoplasms of the connective tissues derived from mesenchymal origins throughout the body, accounting for 1% of adult malignancies and 7% to 15% of pediatric malignancies.¹ Sarcomas of the extremity, which are the scope of this chapter, represent 50% to 60% of all sarcoma diagnoses,² with the thigh being the most common location.³ A deep knowledge of the principles of reconstructive surgery is of paramount importance to the oncological surgeon. In the same manner that tumor invasion of a vital structure can render the disease unresectable, a soft tissue defect that cannot be repaired results in either unacceptable morbidity, severely impairing the patient’s quality of life, or an amputation in the cases of extremity tumors. A current familiarity with state of the art reconstructive techniques helps to identify cases that will present reconstructive challenges while also preparing the surgeon to properly advise the oncologic surgeon and patient of what options are truly tenable. In addition, cooperative efforts between the oncologic surgeon and plastic surgeon are more likely to result in satisfactory treatment of the wound with shorter recoveries and decreased length of hospital stay.

The majority of wounds created by tumor extirpation, whether benign or malignant, can be managed by primary closure or skin grafting. This is not true of complex wounds which are typically large, composite defects like those seen with postradiation ulcerations or traumatic or infected wounds (i.e., osteomyelitis). On occasions when the wound cannot be closed primarily or with a skin graft, the use of flaps becomes the most appropriate option. The type and location of the soft tissue defect will dictate what type of flap is required. Considerations include whether the coverage needed is of skin alone or composite tissues, such as a combination of skin, muscle, and bone. An essential principle of reconstruction of complex defects is the selection of a flap that can most closely replicate the lost tissue, regardless of the complexity of the procedure.

The obligation of the oncological surgeon is to perform what he considers the best extirpative procedure that will, to the highest degree possible, ensure adequate resection of the tumor and best tumor-free survival for the patient. The reconstructive surgeon must be well-versed in all reconstructive modalities so that he may attend to the defect presented, choosing an appropriate reconstruction, regardless of complexity, to assure rapid healing with minimal complications. Specifically, the resection must never be compromised to accommodate reconstruction.

This does not mean that an optimization of the surgical approach through team discussion is prohibited, especially when such discussions are likely to enhance the patients’ outcome. The possibility of working simultaneously with separate teams can also prove to be an important consideration. When possible, tandem procedures will shorten the overall operative time, particularly if the reconstructive surgeon is planning a microvascular reconstruction. Separate operative personnel and instrument setup limits the possibility of cross-field contamination.

Difficult wounds fall under three general categories: (1) chronically infected wounds, (2) wounds over bone devoid of periosteum and over joints, and (3) postradiation wounds.

Chronically Infected Wounds

Chronic wounds where granulation tissue has been allowed to develop and persist for a prolonged period can often be difficult to treat. The granulation tissue is a combination of capillaries, fibroblasts, and bacteria. Therefore, it is essential to debride all of the granulation tissue down to a clean fascial level. Antibiotic therapy and serial debridement may be in order for the larger wounds, depending on the severity of localized infection. After the resolution of infection, the wound can be covered with a skin graft and should heal without problems. When wound debridement leads to exposure of vital structure(s) and/or creates a significant dead-space defect, coverage with a flap of vascularized tissue is indicated.

Exposed Bone Devoid of Periosteum and Exposed Joint

The first step in treating wounds where bone is exposed and devoid of periosteum is to avoid desiccation. This can be accomplished by moist or occlusive dressing changes, such as BIP (bismuth, iodophor, petrolatum). It is always important to remember that skin grafts will not take on an avascular wound beds as is seen in bone stripped of periosteum. Depending on the location and size of the defect, an adjacent fasciocutaneous flap is the simplest way to treat such a wound. However, when dealing with active infection, such as chronic osteomyelitis, the wound should first be treated with adequate debridement followed by a muscle or musculocutaneous flap. It is essential that any cavity be filled in order to prevent potential dead space which can act as a nidus for infection. After resection and reconstruction of sarcoma involving segments of long bone in continuity of major joints, large flap transfers, especially free flaps, are often necessary. In cases when barely sufficient local skin and soft tissue are available for direct closure, postoperative infection or radiation can propagate wound dehiscence, mandating consultation with a plastic surgeon for coverage. Supple soft tissue coverage over joints is vital for restoration of function.

Postradiation Wounds

Advances in radiotherapy have resulted in a marked decrease in injuries to the soft tissues, particularly to the skin. However, all patients will demonstrate radiation changes to the skin that are permanent and vary greatly in severity. The surgical treatment of a postradiation wound consists of extirpation of the ulceration to include the entire radiation field followed by coverage of the defect with muscle or a musculocutaneous flap, and if unavailable, omentum. Clinical clues to determine the affected field of radiation include hyperpigmentation of the skin, lack of the epidermal appendages, as well as a leathery appearance or feeling of the skin. Skin grafts alone are very likely to fail. Local skin flaps similarly may not adhere to the underlying postradiation bed or to the skin edges. Muscle and omental flaps are successful because they bring their own blood supply with origins outside the field of injury. Coverage of the muscle or omentum is accomplished by a split thickness skin graft during the initial reconstruction.

Important advances in limb salvage, particularly in the treatment of sarcomas of the bone, have been made possible by improvements in reconstructive microsurgery and orthopedic implants. In the past, because of the lack of adequate reconstructive options and the fact that more limited resections invariably resulted in local recurrence, radical amputation became the standard.

With the advent of limb sparing resections and modern reconstructive techniques, as many as 90% of patients may be spared an amputation with local recurrence rates under 10%.^2–7

The limb sparing resection techniques include compartmental and wide local excisions. In compartmental excision, the groups of involved muscles from origin to insertion, taking into account the locale of the old biopsy site and the presumed extent of the tumor, are removed. Wide local excision technique seeks to obtain a 2- to 3-cm margin without ever touching the tumor, ideally including one uninvolved fascial plane and the previous biopsy scar. An amputation is indicated when the resection results in a nonfunctional limb or when the disease process involves the entire extremity.