The Role of the Pediatric Plastic Surgeon in Limb Salvage Surgery for Osteosarcoma of the Lower Extremity

Abstract

Limb salvage for management of osteosarcoma of the lower extremity has become the mainstay of treatment for patients with malignant bony and soft tissue tumors. The knee has become a special area of concern for the reconstructive surgeon due to the high rate of wound complications and difficulties of soft tissue reconstruction. With the availability of new prosthetic implants, the advancement of surgical soft tissue techniques and introduction of adjuvant and neoadjuvant chemotherapy, resection and reconstruction has become the standard approach for patients presenting to St. Jude Children's Research Hospital. The pediatric plastic surgeon's role usually requires handling of wound complications in these reconstructive procedures. This article will discuss the authors' approach to dealing with wound complications in this difficult patient population and their interaction with the orthopedic oncologic service in obtaining primary resection and soft tissue coverage.

Modified Vertical Rectus Abdominis Musculocutaneous Flap for Limb Salvage Procedures in Proximal Lower Limb Musculoskeletal Sarcomas

“…Radiation and chemotherapy in addition to limb preservation through recent refinement in reconstructive surgery have improved the local, systemic control and the subsequent overall survival [10, 11]. The most common complications of limb salvage procedures for musculoskeletal sarcomas surgery have been problems with wound healing, flap necrosis, and wound infections [1, 6]. Infections associated with prosthetic replacement after tumor resection in these patients are common and serious complications as they are often subjected to extensive soft tissue dissection and long operating times while systemically immunocompromised [5, 6, 12].…”

“…Limb salvage remains a major objective in contemporary management of bony and soft tissue sarcomas of the pelvis and lower extremities [1, 2]. Radical oncological salvage procedures performed in this area can develop significant wound complications that result from a high incidence of infection, dehiscence, or flap necrosis aggravated by the paucity of well-vascularized local soft tissue and systemically immune-compromised patients [3–6].…”

The Current and Future Therapies for Human Osteosarcoma

“…Advances in imaging technique, neoadjuvant chemotherapy regimens and improvements in surgical methods have allowed limb-salvage surgery to become the predominant alternative to amputation [25,30,39,41-46]. Specifically, improvements in MRI have helped surgeons to better delineate the extent of the primary tumor and its relation to the neurovascular margin, precisely reducing margins and making limb-salvage more feasible [21,22,29].…”

“…By combining current chemotherapeutic regimens with limb-sparing operations, greater than two-thirds of patients with non-metastatic OS of the extremities are long-term survivors with an overall limb preservation rate of greater than 80% [21,38]. Limb-salvage surgery results in improved limb functionality, appearance and psychological outcomes while having local recurrence and survival rates similar to those undergoing amputation [25,21,39,40]. However, because of the removal of the primary tumor with adequate margins, limb-salvage procedures often result in large bone and soft tissues losses and associated long recovery times, poor joint stability and partial loss of function [25,39,44,45].…”

“…Limb-salvage surgery results in improved limb functionality, appearance and psychological outcomes while having local recurrence and survival rates similar to those undergoing amputation [25,21,39,40]. However, because of the removal of the primary tumor with adequate margins, limb-salvage procedures often result in large bone and soft tissues losses and associated long recovery times, poor joint stability and partial loss of function [25,39,44,45]. Nonetheless, since limb-salvage more successfully preserves limb function and provides improved psychological and physiological benefits, it is preferred to amputation in the vast majority of OS cases [21,25,40,44,128-131].…”