Functional reconstruction of sarcoma defects utilising innervated free flaps

Abstract

Soft-tissue reconstruction following preoperative radiotherapy and wide resection of soft tissue sarcoma remains a challenge. Pedicled and free tissue transfers are an essential part of limb sparing surgery. We report 22 cases of sarcoma treated with radiotherapy and wide excision followed by one-stage innervated free or pedicled musculocutaneous flap transfers. The resection involved the upper limb in 3 cases, the lower limb in 17, and the abdominal wall in 2. The flaps used for the reconstruction were mainly latissimus dorsi and gracilis. The range of motion was restored fully in 14 patients. The muscle strength of the compartment reconstructed was of grades 4 and 5 in all patients except one. The overall function was excellent in all the cases with functional scores of 71.2% in the upper limb and 84% in the lower limb. The only 2 major complications were flap necrosis, both revised with another flap, one of which was innervated with restoration of function. Innervated flaps are valuable alternatives for reconstruction after sarcoma resection in the extremity and in the abdominal wall. The excellent functional results are encouraging, and we believe that innervated muscle reconstruction should be encouraged in the treatment of sarcoma after radiotherapy and wide resection.

Figure 1

Histology of excised innervated flap (gracilis) after 14 months. (a) Muscle fibres show no features of denervation atrophy, Haematoxylin and Eosin 100x. (b) Nerve section shows normal fasciculi without reactive axons and normal axonal density, APP Immunohistochemistry 200x. (c) Nerve section shows well preserved myelinated fibers axons with normal density, Masson stain 200x.

Figure 2

Patient treated for high-grade pleomorphic sarcoma of the anterior compartment of the thigh. (a) Intraoperative image. The resection involved the entire quadriceps compartment and measured 35 × 14 × 25 cm. (b) The reconstruction was performed using innervated TRAM. (c, d) At 24 months postoperatively, the patient demonstrated full extension of the knee, flexion limited to 100 degrees, and muscle strength of 5.

Figure 3

Patient treated for liposarcoma of the posterior thigh with wide resection involving hamstrings, reconstructed with innervated latissimus dorsi flap. Clinical outcome at 14 months post-op. (a) Full extension. (b) Active flexion. Muscle strength of posterior compartment of the thigh: 4.

Figure 4

Patient treated for MFH of the anterior compartment of the arm; the resection involved the biceps and the brachialis muscles, and denervation of brachioradialis. The reconstruction has been obtained using free innervated gracilis and transfer of FCU to remaining brachialis. Clinical outcome at 12 months post-op shows full active flexion at the elbow. The muscle strength of the anterior compartment of the arm was 4.