Working with Orthopedic Oncologists: When to Offer Immediate and when and why to Delay Definitive Reconstruction of an Extremity

Abstract

A review of patients that were treated jointly by the plastic and the orthopedic surgery teams from 2011 to 2015 to evaluate the timing of definitive reconstruction of extremity defects was undertaken. The cohort consists of 81 patients, of which 4 presented with either a high-risk lesion or an advanced squamous cell carcinoma and of which the remaining 77 patients presented with different types of extremity sarcomas. In 58 cases, immediate-definitive reconstruction was performed, while in 23 cases the definitive procedure was delayed. Immediate definitive reconstruction, concurrent with ablative procedures, was offered whenever possible. In 16 cases, delayed reconstruction was due to diagnostic uncertainty (uncertain diagnosis per se or non-established negative margins). In 6 cases, delayed reconstruction was performed because of infection, in 1 case a bleeding disorder necessitated workup and in another, the intraoperative histology necessitated a plan-change, wound temporization and preparation of an arteriovenous fistula for microsurgical reconstruction. Indications for delayed reconstruction can be related to systemic conditions, donor or recipient site issues (infection, suspicion of margin-problems or tumor "not in continuity"). Although frozen sections have an overall diagnostic accuracy of 90%, changes in management were related to the inadequacy of frozen material, sampling errors resulting from heterogeneity or non-appositional growth of malignancy. A high rate (28%) of delayed reconstruction corresponds with new data reaffirming an old paradigm (radically excised margins "make a difference"), and with objectives dictated by customized, personalized, multimodal approaches. Wound temporization was offered whenever definitive reconstruction couldn't be performed immediately. Limb sparing, with the utilization of temporary spacers or distractors, mega-prostheses, or trials of reimplanting formerly tumorous bone autografts, which have been sterilized to eliminate malignant cells -may all necessitate temporary coverage or staged repair. Authors' clinical experience was evaluated in the context whether the rationale behind immediate versus delayed reconstruction was optimal.