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Editorial |
Winship Cancer Institute, 1365B Clifton Road, Atlanta, Georgia 30322
Correspondence: Address correspondence and reprint requests to: Grant W. Carlson, MD; E-mail: grant_carlson{at}emory.org.
The current management of soft tissue and bone sarcomas includes radiation, surgery, and often chemotherapy. Limb salvage surgery has become the standard approach for extremity sarcomas after trials showed survival equivalence to amputation. Reconstruction has evolved to include alloplastic materials for joint and bone replacement and vascular reconstruction, as well as free tissue transfer to provide stable soft tissue coverage, vascularized bone, and functioning muscle replacement. Flap reconstruction has numerous advantages over primary wound closure. It allows larger resections and provides vascularized tissue with an independent blood supply. This reduces wound complications, especially in patients receiving preoperative radiotherapy. Wound complication rates range from 25% to 44% for soft tissue sarcomas resected in the setting of radiotherapy.1–4 Barwick et al.2 reported on 82 patients with soft tissue sarcomas who were treated with preoperative radiation. Thirty-seven patients underwent primary wound closure, and 41 patients required a vascularized tissue flap. The use of a flap resulted in a lower complication rate (19% vs. 51%), fewer secondary procedures (10% vs. 35%), a shorter hospital stay (15 vs. 48 days), and improved limb salvage (97% vs. 91%).
Rivas et al.5 are to be congratulated on using the Enneking outcome measurement scale to provide objective functional outcome data after extremity reconstruction.5 Success in reconstruction has often been reported in terms of flap survival and stable wound coverage. Few studies have examined an objective functional evaluation of extremity reconstruction.6–8 Serletti et al.8 reviewed the functional outcome of soft tissue reconstruction for limb salvage in 28 patients (lower extremity, n = 23; upper extremity, n = 5) with sarcoma. Thirty-three reconstructive procedures were performed: 16 free flaps and 17 local flaps. They found no functional differences for the upper versus lower extremity, immediate versus delayed reconstruction, or free flap versus pedicled flap.
In their review of 32 patients (lower extremity, n = 25; upper extremity, n = 7) Rivas et al.5 found that free flaps were superior to pedicled flaps in the functional evaluation of lower extremity reconstruction. The article contains many uncontrolled variables, and this makes any form of comparison problematic. There was a mixed patient population comprising 16 bone sarcoma patients, 10 soft tissue sarcoma patients, and 8 skin cancer patients. Bone reconstruction was performed in five patients. The functional outcome of extremity reconstruction depends on many variables, including the extent of resection (vascular, nerve, or bone involvement), administration of adjuvant radiotherapy, postoperative complications, and site. Radiation was administered to 70% of the patients, but the authors did not stratify this by reconstructive method. It would seem that free flap reconstruction had a lower wound complication rate than pedicled flaps (11% vs. 50%) in their series.
Free flap reconstruction has several advantages over pedicled flaps. There is an independent blood supply that has freedom from rotation arcs. There is no disruption of local vascular and lymphatic supply. Free flaps provide vascularized tissue from outside the radiation fields in patients treated with preoper-ative radiation. In patients receiving adjuvant radiation, free flaps potentially reduce the size of radiation field if regional pedicled flaps are used. Free flaps also can provide specialized tissue, such as vascularized bone and innervated muscle, which potentially improve functional outcomes. The conclusion of the authors—that free flap lower extremity reconstruction gives better functional results than that with pedicled flaps—seems like a self-fulfilling prophesy, but there is an inherent selection bias when a reconstructive method is chosen. Large, complex defects often can be closed only with a free tissue transfer. Proximal extremity defects are very amenable to pedicled flap closure with latissimus dorsi or rectus abdominis flaps. The expertise of the reconstructive surgeon also plays a large role in flap selection and results. Microsurgery has evolved to the point where success can no longer be measured by flap survival and wound closure. Objective analysis of functional results such as those presented by Rivas et al.5 should be the standard measure of extremity reconstruction.
Received for publication January 5, 2006. Accepted for publication January 5, 2006.
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