The Spare Parts Concept in Sarcoma Surgery: A Systematic Review of Surgical Strategies

Abstract

Introduction Sarcomas of the extremities are relatively infrequent tumors, accounting for 1% of adult malignancies [1]. Three decades ago, sarcomas were frequently primarily treated by limb amputation, due to the absence of other therapeutic options to minimize local recurrence rates. However, with the advent of multimodality treatment, limb-salvage strategy has been favored [2]. In a prospective randomized study [3], found no statistically significant differences in survival rates when comparing limb-sparing surgery plus radiotherapy with limb amputation. Achieving adequate resection margins is of paramount importance, although there are no standardized guidelines that define ideal margins [4]. The objective is to perform a wide resection with negative margins (no residual microscopic disease). For this reason, it is sometimes inevitable to have to resort to amputation of the limb to reach acceptable margins of resection. It is in these cases when the "spare parts concept" intervenes, being it defined as reutilizing tissues from amputated or unsalvageable limbs to reconstruct large defects or to obtain an optimal proximal stump with the needed length for subsequent prosthetization. Either of them can be achieved without causing additional donor-site morbidity [5]. This publication aims to perform a complete and systematic revision of the main techniques encompassed in this concept, as well as incorporating our own-experience tips on its surgical approach. Methods This systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [6] and AMSTAR 2 guidelines [7]. Two electronic databases (PubMed and Cochrane Central) were queried from January 14, 2019 to April 25, 2019. Research was performed with the terms "Spare Parts Surgery", "Sarcoma Surgery", "Fillet Flap", "Sarcoma Reconstruction" and "Sarcoma Reconstructive Surgery". All resulting articles-from inception to January 2019-were compiled, and duplicate titles removed. The database searches yielded 132 non-duplicated results. Two reviewers screened the remaining titles and abstracts, collecting all articles which included data about surgical techniques encompassed in spare parts concept, indications, outcomes, prognosis, surgery-related complications and technical details. Full-text revision of 74 publications was performed. Finally, 31 articles were selected according to aforementioned criteria. Operative Techniques Although techniques included in the spare-part surgery concept allow primary reconstruction of the limb and improve functional results after amputation, there is neither a surgical manual nor a standardized algorithm for the surgeon to follow. The unique aspect of spare-part surgery is that the surgeon has to assess and create a strategy on the spot to maximize the use of tissues that

Tratamiento multidisciplinario de condrosarcoma gigante de fémur proximal mediante hemipelvectomía externa y reconstrucción con colgajo pediculado tipo Fillet flap

“…Dada esta situación, una alternativa reconstructiva es utilizar las estructuras no recuperables del miembro amputado más allá del margen tumoral, lo cual se denomina colgajo tipo "Fillet flaps" (9) . Esta técnica surge del concepto clave en cirugía plástica "spare part" o "piezas de repuesto", definiéndose como la reutilización de tejidos de miembros amputados o insalvables para reconstruir grandes defectos obteniendo un muñón proximal óptimo con la longitud necesaria para su posterior prótesis (10,11) . De esta manera se ofrece a los defectos de partes blandas de las hemipelvectomías la opción de lograr una adecuada cobertura con el aporte de piel, musculo, fascia y hueso a través de colgajos pediculados o libres resecados del miembro amputado (12) .…”

Management of Free Fillet Flap Transfers in Large Oncologic Resections

“…A fillet flap is a reliable flap that provides healthy nonradiated otherwise discarded tissue for coverage of large oncologic resections without creating a new donor site. 1 Decrease in healing time may expedite adjuvant treatment therapy and prosthetic fitting and preserve other potential myocutaneous flaps for any future reconstruction.…”