Phẫu Thuật Tạo Hình (Tập 4): Chi Dưới, Thân Mình Và Bỏng – Neligan (2018)

65
Treatment and surgical techniques
A
B
Fig. 2.17  (A) Exposed left patellar tendon with soft-tissue defect in a 56-year-old male patient with an underlying knee prosthesis. (B) Posterior approach via a midline
incision for harvest of a medial gastrocnemius muscle flap. The posterior and anterior surface of the muscle fascia can be scored to achieve greater length and the muscle
origin can also be detached for the same purpose. (C) Wound was debrided and defect covered with a tunneled pedicle medial gastrocnemius muscle flap. Tunnel must be
adequately released so that no pressure is exerted on the muscle and its pedicle. (D) Final flap inset and coverage with a split-thickness skin graft.
C
D
A
Fig. 2.18  (A) Alternatively, an anterior approach can be used to harvest a gastrocnemius flap for knee defects, and this avoids any positional changes. Posterior and
anterior muscle fascia scoring are also performed in order to maximize muscle length. The tendinous portion of the muscle can also be used to anchor the flap and provide
additional well-vascularized tissue. (B) Final flap inset and split-thickness skin grafting with complete wound coverage.
B

66
SECTION I
CHAPTER 2 • Management of lower extremity trauma
Fig. 2.19  Anterolateral thigh (ALT) flap harvest showing perforators originating
from the descending branch of the lateral circumflex femoral artery (DBLCFA). The
DBLCFA is seen coursing between the vastus lateralis laterally and the rectus
femoris medially. Once the rectus femoris muscle has been dissected and retracted
medially, all perforators from the DBLCFA become easily visible. The most direct
and least intramuscular perforator is then selected for flap harvest.
Musculocutaneous
perforator passing
through the vastus
lateralis muscle
ALT flap
Septocutaneous
perforators
DBLFCA
Vastus lateralis
Intermuscular septum between
vastus lateralis muscle and
rectus femoris muscle
Rectus femoris muscle
Fig. 2.20  Interperforator flow allows communication with multiple adjacent
perforators via direct and indirect linking vessels.
Multidirectional interperforator flow
= direction of interperforator flow
= perforator
Fig. 2.21  A large (extended) anterolateral thigh flap can be harvested based on a
single perforator. High arterial filling pressures from the selected perforator allow
interperforator flow and increased flap vascular territory.
Recurrent flow
through the
subdermal plexus
Recurrent flow through the
subdermal plexus
incorporates distal linking vessels between LCFA, common
femoral, and superficial femoral arteries53 (Figs. 2.19–2.22).
Additionally, the reverse ALT flap has also been described as
a distally based pedicled flap in lower extremity reconstruc-
tion.54 Consideration may be given to supercharging this
flap through anastomosis of the proximal LCFA to leg
donor vessels (e.g., anterior tibial artery) if vascularity is
questionable.55
In the leg, the sural artery flap and reverse sural artery flap
provide coverage of the knee and calcaneal region, respec-
tively. The sural artery flap is based on a direct cutaneous
branch of the sural artery and lesser saphenous vein. The
reverse sural artery flap is primarily based on septocutaneous
perforators from the peroneal artery and includes the lesser
saphenous vein and median cutaneous sural nerve56 (Fig.
2.23). Venous congestion and partial flap ischemia are possible
complications of the reverse sural artery flap and can be
overcome by a two-stage delay procedure or venous super-
charging57,58 (Fig. 2.24).
Free tissue transfer – muscle
Larger defects of the lower extremity that require obliteration
of dead space often warrant the use of a muscle-based free
flap in combination with split-thickness skin graft. Commonly
used muscles include the latissimus dorsi (thoracodorsal
artery) (Figs. 2.25–2.27), rectus abdominis (deep inferior epi-
gastric artery) (Fig. 2.28), serratus anterior (lateral thoracic
artery or branch to serratus anterior from thoracodorsal
artery), and gracilis (ascending branch of medial circumflex
femoral artery) (Figs. 2.29 & 2.30). For small to moderate
defects, muscle-sparing versions of the latissimus dorsi and
rectus abdominis flaps can be excellent options without sac-
rificing donor site function.

67
Treatment and surgical techniques
A
B
C
D
Fig. 2.22  Large degloving injury of the left lower extremity with exposure of the
medial malleolus, Achilles tendon, calcaneus, and extensor tendons. Following
radical debridement, resurfacing was done with an extended anterolateral thigh (ALT)
flap. The ALT flap was later liposuctioned for improved contour, and the patient was
able to wear his normal footwear and ambulate at his preinjury level.
E

68
SECTION I
CHAPTER 2 • Management of lower extremity trauma
A
B
Fig. 2.23  (A) Left lower extremity defect with exposed Achilles tendon and calcaneus. Sural artery flap designed along a vertical axis centered from the midpoint between
the lateral malleolus and the Achilles tendon and the midpoint of the popliteal fossa. Maximal peroneal perforator density can be found within 8 cm of the lower transverse
line. This location represents the proximal extent of the sural artery flap. The sural artery flap can be safely extended to three-quarters of the leg proximally. A delay
procedure can be considered in patients with advanced age and medical comorbidities (e.g., diabetes) in order to maximize arterial perfusion and venous outflow.
(B) Subfascial elevation of the sural artery flap from proximal to distal with early identification of the sural nerve and artery, which are incorporated into the flap. Note that
this flap is principally based on peroneal perforators and can alternatively be harvested without sacrifice of the sural nerve. (C) Sural artery flap in situ following elevation
and recipient site debridement. (D) Final flap inset without tension. Donor site is closed primarily and the addition of a split-thickness skin graft as needed. Liberal use of
skin grafting should be done proximal to the flap base in order to minimize undue pressure on the perforators.
C
D
Fig. 2.24  Two weeks postsurgical delay procedure of a sural artery flap in a
diabetic 84-year-old patient. This delay procedure allows for a clear demarcation of
flap viability. Note the proximal ischemic portion of the flap was discarded prior to
definitive flap transfer.
Free tissue transfer – fasciocutaneous
One of the most versatile and popular fasciocutaneous free
flaps used in lower extremity reconstruction is the ALT flap.
This can be converted into a sensate flap by incorporating the
lateral femoral cutaneous nerve, which is useful in distal third
of a leg and foot reconstruction where sensation is important.
This flap is described above. The ALT flap can also be har-
vested as a thinner adipofascial flap that allows primary
donor site closure. This is very useful in patients who have
an unsuitable ALT donor site due to excessive thickness
(Figs. 2.31 & 2.32).
A
B
Fig. 2.25  (A) Complex left lower extremity defect with a comminuted fracture of
the proximal tibia. (B) Defect following radical debridement and conversion of
multiple wound units to a simpler single wound unit.

69
Treatment and surgical techniques
C
D
(C) Free latissimus dorsi muscle flap harvested to provide coverage of a large surface area. This muscle flap also allows important deep space
obliteration in cases involving comminuted fractures with complex 3D wound defects. (D) Circumferential coverage of the lower extremity wound with a latissimus dorsi flap
and split-thickness skin graft. Anastomosis was performed to the posterior tibial artery and vein distal to the zone of injury. Vessels distal to the zone of injury have the
advantage of being more superficial, which facilitates vessel access and microsurgery.
Fig. 2.25, cont’d
B
A
Thoracodorsal artery
Descending branch of
thoracodorsal artery
Transverse branch of
thoracodorsal artery
Serratus anterior
External oblique
Latissimus
dorsi
C
Fig. 2.26  (A) Alternatively, for smaller defects of the lower extremity, a free muscle-sparing latissimus dorsi flap can be used. This flap retains all of the advantages of its
full latissimus dorsi counterpart without sacrificing donor muscle function. The muscle-sparing latissimus dorsi flap can be based on either the descending or transverse
branch of the thoracodorsal artery and vein. (B) Muscle-sparing latissimus dorsi myocutaneous flap for lower extremity reconstruction. (C) Donor site following free
muscle-sparing latissimus dorsi flap harvest. Note preservation of the anterior axillary line and the majority of the latissimus dorsi muscle.

70
SECTION I
CHAPTER 2 • Management of lower extremity trauma
A
B
Fig. 2.27  (A) Right ankle wound with exposed medial malleolus and soft-tissue defect in a 45-year-old patient. (B) Thin thoracodorsal artery perforator flap harvested for
resurfacing a medial ankle defect. (C) Thoracodorsal artery perforator flap donor site with preservation of entire latissimus dorsi muscle. Flap was based on a direct
cutaneous branch, which followed the anterior border of the latissimus dorsi muscle. (D) Thoracodorsal artery perforator flap (8 × 20 cm) used to resurface the medial right
ankle and malleolus.
C
D
Fig. 2.28  (A) Right medial ankle defect with exposed medial malleolus and
tendons. Radical debridement was performed, and posterior tibial artery and vein
were prepared as recipient vessels. Posterior tibial vessels are our recipient vessels
of choice for medial and anteromedial defects. They provide large, dependable
vessels that are usually well protected deep from the zone of injury. (B) Coverage of
the medial ankle defect with a free muscle-sparing rectus flap. (C) Final inset and
coverage with a split-thickness skin graft. Note that the external fixator can be
temporarily dismantled for better vascular access and easier microsurgery.
A
B
C

71
Treatment and surgical techniques
Fig. 2.29  (A) Dissection of a free gracilis flap with exposure of the medial circumflex femoral artery and venae comitantes. (B) Gracilis free flap inset with sheet
split-thickness skin graft. (C) Final postoperative result after 1 year with low-profile contouring of the free gracilis flap. Note that this patient underwent minor debulking of
the gracilis muscle at 6 months postoperatively. A dermatome was used for muscle debulking and also for split-thickness skin graft removal. The skin graft was recycled
back on to the gracilis flap immediately following muscle shaving in order to avoid another skin graft donor site.
A
Medial circumflex femoral artery
and venae comitantes
Gracilis muscle
B
C
A
Fig. 2.30  (A) Exposed extensor tendons, left talus, distal tibia, and fibula, with significant dead space. This open joint creates a complex 3D defect, which can be
effectively obliterated with an expendable free gracilis flap. (B) Postoperative result after 6 months with good contouring of the anterior ankle and minimal bulk. Denervated
muscle atrophies significantly over time and contours well to its recipient site.
B

72
SECTION I
CHAPTER 2 • Management of lower extremity trauma
Fig. 2.31  (A–C) Right lateral ankle soft-tissue defect and exposed hardware
resurfaced with a thinned and neurotized anterolateral thigh flap based on a lateral
branch of the femoral cutaneous nerve. The periphery of the flap can also be thinned
for better inset and less bulk. We do not recommend aggressive primary thinning of
the anterolateral thigh flap and prefer to do this secondarily if necessary.
(D) Postoperative results 6 months later with stable right-leg wound coverage and
healed donor site. ALT, anteromedial thigh.
A
B
C
D
Other fasciocutaneous free flaps used in lower extremity
reconstruction include the radial forearm flap and the AMT
flap. The radial forearm flap is based on the radial artery,
which runs proximally between the brachioradialis and pro-
nator teres. It can be made sensate through the incorporation
of the lateral or medial antebrachial cutaneous nerves. The
AMT flap is supplied by a septocutaneous branch of the
LCFA, commonly arising between the medial border of
the rectus femoris and the sartorius59 (Fig. 2.33). It provides a
large skin paddle, with a well-hidden donor site. Addition-
ally, it can be designed as a vascular flow-through flap for
combined soft-tissue/vascular reconstruction.
Skeletal reconstruction
Options for bony reconstruction of the lower extremity
include autogenous cancellous bone graft, vascularized bone
graft, and distraction osteogenesis. Autogenous cancellous
bone grafts are typically used to fill small defects in bone
(Fig. 2.34). While it is possible to bridge larger gaps (8–10 cm)
with autogenous cancellous bone graft, it is not favorable.
In this situation, vascularized bone graft or distraction
osteogenesis is preferred. The most commonly used donor of
vascularized bone graft is the fibula based on segmental and
nutrient vessels of the peroneal artery. Alternative options

73
Treatment and surgical techniques
A
B
Fig. 2.32  (A) Right leg anterolateral soft-tissue defect and exposed extensor tendons in a 9-year-old child following a motor vehicle accident. (B) Design of a contralateral
extended anterolateral thigh (ALT) flap. (C) The ALT flap was converted into an adipofascial ALT flap in order to minimize bulk and maximize flap size while allowing primary
donor site closure. A 25 × 11 cm adipofascial ALT flap was used for reconstruction and permitted entire wound coverage. (D) Adipofascial anterolateral thigh flap inset and
coverage with a split-thickness skin graft. The posterior tibial artery and vein were used as reliable recipient vessels.
C
D
Fig. 2.33  A 22-year-old male with exposed tibia following intramedullary nailing of
a closed tibia fracture. (A–C) In this case no suitable perforators were found for an
anterolateral thigh flap from the right thigh. Therefore dissection was carried out
medially over the rectus muscle and a large perforator coursing through the rectus
femoris was used to harvest an anteromedial thigh flap instead. (D) Postoperative
results 6 months later with stable right-leg wound coverage and healed donor site.
A
B
C
D

74
SECTION I
CHAPTER 2 • Management of lower extremity trauma
most Gustilo grade III tibial fractures, with closure being
achieved through delayed primary, secondary, and skin graft
methods. This is not only cost-effective but also makes it pos-
sible to avoid flap surgery related complications. Additionally,
NPWT systems can be used in fasciotomy wounds and inci-
sional edema management.62
Amputation
In the situation where amputation is indicated, or the trauma
has resulted in a complete/near-complete amputation, it is
important to consider management of the amputation stump
from a prosthetic standpoint. Preservation of length and cre-
ation of stable soft-tissue coverage are of paramount impor-
tance. If at all possible, maintaining a below-knee amputation
length is important, as this is better tolerated and has much
less energy demand for mobilization. In cases where there is
inadequate soft-tissue coverage of a below-knee amputation
bony stump, it is possible to use free flaps to maintain length.
These can include musculocutaneous and fasciocutaneous
options, similar to those discussed above. One can also
consider the use of “spare parts” surgery, whereby portions
of the amputated extremity (if intact/appropriate) can be
used to reconstruct the remaining defect. Finally, if there is
muscle coverage of the bony stump but no skin coverage,
the use of skin grafts is appropriate to provide soft-tissue
coverage.
Treatment of associated complications
Rhabdomyolysis
The concept of acute renal failure associated with crush inju-
ries was first documented by Bywaters and Beal in 1941. It
was their observation that patients who had been buried for
several hours (during the Blitzkrieg attacks in London) pre-
sented with swelling and anesthesia of their limbs, with
progression to pallor, coldness, sweating, and unstable vital
signs (shock). Eventually arterial pulses diminished and urine
output dropped, coincident with an increase in albumin and
dark brown casts within it. Patients subsequently developed
hyperkalemia and renal failure, leading to an accelerated
death.
The pathophysiology of rhabdomyolysis involves muscle
injury and resultant myocyte damage, which results in
sodium and calcium influx into the cytoplasm and potassium
efflux into the extracellular fluid.63 As a result of this myocyte
damage, a large quantity of breakdown products are released
into the blood stream, and some of them, such as myoglo-
bin, induce renal failure. The diagnosis of rhabdomyolysis
is supported by a positive urine dipstick for hemoglobin,
in addition to laboratory confirmation of myoglobin and
quantitative assessment. The severity of acute renal failure
that ensues can be predicted by the presence of a urine myo-
globin concentration >20 mg/L.64 Renal failure associated
with rhabdomyolysis has three main mechanisms: (1) tubular
obstruction; (2) tubular damage by oxidant injury; and (3)
vasoconstriction.63
In the treatment of rhabdomyolysis, the most important
component is early volume replacement to prevent the devel-
opment of renal failure. Alkalinization of the urine using
include the vascularized iliac crest graft (deep circumflex
iliac artery) and the vascularized scapular graft (circumflex
scapular artery). Grafted vascularized bone will hypertrophy
over time, but it takes months to a few years. For defects over
10 cm, distraction osteogenesis is considered. This involves
the division of cortical bone with preservation of the conti-
nuity of cancellous bone and bloody supply at metaphysis
(corticotomy). Half pins are applied to both segments of the
bone, and an external fixator is applied. Distraction starts
about 10–14 days later with a rate of 1 mm per day. The whole
process can take more than 1 year. It can be very arduous and
accompany complications such as pin site infection, pain, and
nonunion.
Negative-pressure wound therapy in lower
extremity defects
As advances in wound care have evolved over the past
decade, there is increasing reliance on their use in the manage-
ment of complex soft-tissue wounds. In particular, the use of
commercially available Negative Pressure Wound Therapy
(NPWT) devices is becoming more commonplace. It is thought
that NPWT provides edema control and facilitation of wound
closure via the application of soft-tissue macrostrain forces,
stimulation of fibroblast proliferation, and tissue granulation
via macrostrain at a cellular level, suppression of destructive
wound proteases, facilitation of bacterial clearance from the
wound, and prevention of cross-contamination in a hospital
environment.60 DeFranzo et al.61 used a NPWT system in 75
patients with exposed tendon, bone, or hardware, excluding
those with frank osteomyelitis. All wounds underwent surgi-
cal debridement until viable tissues were present in the wound
base, prior to the application of the NPWT device. The authors
found that granulation tissue was often present by the second
dressing change, with a reduction in wound edema and bacte-
rial count. All patients achieved stable wound coverage via
delayed primary closure, skin graft, or local flap, with no need
for free tissue reconstruction. In their assessment of trends in
lower extremity reconstruction, Parrett et al. 50 found that
there was a trend down the reconstructive ladder, with a
decreasing incidence of free flap reconstruction and more
frequent use of NPWT devices. They stated that at their center
the NPWT system was used in 50% of open fractures and
Fig. 2.34  Elevation of previous free muscle-sparing rectus muscle to medial distal
third of right leg in order to remove methyl methacrylate and place definitive bone
graft. Healed muscle flaps can be easily re-elevated during secondary procedures
such as bone grafting or hardware removal.

75
Postoperative care
compartment syndrome can lead to nerve damage and muscle
necrosis. Acute compartment syndrome involves a build-up
of pressure within a non-elastic muscle compartment that is
surrounded by fascia and bone. In the lower extremity there
are four compartments: (1) anterior; (2) lateral; (3) superficial
posterior; and (4) deep posterior. Compartment syndrome
typically results from bleeding or edema within the compart-
ment. Edema can create a barrier to perfusion, which results in
hypoxia and acidosis. This is a self-perpetuating cycle, as this
leads to further capillary permeability and fluid extravasa-
tion, worsening the edematous state.70 The pathophysiology
of compartment syndrome involves increasing interstitial
pressure. This leads to increased intraluminal venous pres-
sure in an effort to avoid vascular collapse. As a result, there
is a decreased gradient between arterioles and veins, and
capillary blood flow thus decreases and results in ischemia.
The muscle undergoes ischemic scar formation, and necrosis
leads to myoglobinemia.
The classic description of compartment syndrome was
provided by Griffiths, in which he described the “four Ps”
– pain, paresthesia, paresis, and pain with stretch.71 This
has been further expanded to “six Ps” with the addition of
pulselessness and poikilothermia. Compartment syndrome
is relatively uncommon, but should be anticipated in situations
of high-velocity trauma, in patients on blood thinners, and
with lower extremity vascular occlusion or disruption. Pain
is the earliest and most sensitive clinical sign. Confirmation
of the diagnosis can be achieved by measuring the intracom-
partmental pressure. The absolute threshold for fasciotomy
has been debated, with some favoring pressures greater than
30 mmHg and others looking at the difference between com-
partment pressure and mean arterial pressure (<30 mmHg
below mean arterial pressure significant), or diastolic pressure
(<30 mmHg below diastolic pressure significant).70
Following diagnosis, the treatment consists of urgent
surgical decompression of all four compartments. Multiple
approaches have been described, but the most common tech-
niques are release via a single lateral incision or combined
anterolateral and posteromedial incisions. The single-incision
technique involves an incision in line with the fibula extend-
ing from just distal to the head of fibula to 3–4 cm proximal
to the lateral malleolus. Longitudinal fasciotomies of the
anterior and lateral compartments are performed, followed by
subcutaneous dissection posteriorly to access the superficial
and deep posterior compartments. In the two-incision tech-
nique, an anterolateral incision is placed between the tibial
crest and the fibula over the anterior intermuscular septum.
Fasciotomies of the anterior and lateral compartments are
carried out through this incision. The posteromedial incision
is placed 2 cm posterior to the posteromedial edge of the tibia.
This allows access to the superficial posterior compartment,
and, following division of the soleal bridge, the deep compart-
ment can be accessed.
Postoperative care
Antibiotics
In 2009 the EAST practice management group published
updated guidelines for antibiotic use in open fractures.72
Based on their literature review, they made several
sodium bicarbonate (to a target pH 7.0) may be beneficial for
washout of myoglobin and the prevention of lipid peroxida-
tion and renal vasoconstriction. The use of mannitol is more
controversial and may not be better than volume expansion
alone.65
Fat embolism
Fat embolism is a rare entity, but occurs most commonly as a
result of long bone fractures and polytrauma. It may be related
to excessive pseudomotion of unstable fracture or internal
fixation with IM nail. It is most common in young males aged
10–40 years and is rare in children and the elderly. This may
be related to the low fat content of bone marrow in children
and the minimal trauma fractures that tend to occur in the
elderly.66
Two theories regarding the pathophysiologic mechanism of
fat embolism syndrome (FES) exist – the mechanical hypothesis
and the biochemical hypothesis. The mechanical hypothesis
postulates that an increase in IM pressure forces marrow par-
ticles, fat, or bone fragments into the circulation via the open
venous sinusoids. This leads to obstruction of peripheral and
lung microcirculation. This results in ventilation–perfusion
mismatch, low partial pressure of oxygen, and low oxygen
saturation. Cerebral and renal embolization may contribute
to the symptoms. The biochemical hypothesis postulates that
physiochemical alteration occurs when fat globules are acted
upon by lipoprotein lipase, resulting in the release of free fatty
acids. This results in the release of toxic intermediates that
can cause direct injury to pneumocytes and lung endothelial
cells.67
FES is characterized by progressive respiratory insuffi-
ciency, deteriorating mental status, and petechial rash
(major diagnostic criteria). Minor diagnostic criteria include
pyrexia, tachycardia, retinal changes, jaundice, oliguria/
anuria, thrombocytopenia, high erythrocyte sedimentation
rate, and fat macroglobulinemia. According to Gurd and
Wilson, the diagnosis of FES involves two major criteria, or
one major plus four minor criteria plus fat microglobu-
linemia.68 Typically, FES occurs within 24–72 h after injury
and is largely a clinical diagnosis. Laboratory investigations
may include an arterial blood gas to diagnose hypoxemia and
cytologic examination of urine, blood, or sputum looking for
fat globules. Chest radiography may be normal in these
patients, prompting investigation with chest CT or bronchoal-
veolar lavage looking for fat-laden macrophages.69 Because of
the lack of specific diagnostic criteria or investigations, the
incidence of FES is likely to be underestimated.
Once FES is suspected, the management is largely sup-
portive and usually involves management of the hypoxemia.
Prophylactic measures in those considered at risk for FES
are most important. These include early stabilization of
long bone/pelvic fractures, minimizing IM pressures during
reaming, and irrigation of marrow prior to insertion of pros-
theses. Pharmacologic therapies have been disappointing
and, despite initial interest in using steroids, there have not
been any level 1 studies supporting their use.
Compartment syndrome
Compartment syndrome is a rare, but potentially devastat-
ing, complication of lower extremity trauma. Undiagnosed

76
SECTION I
CHAPTER 2 • Management of lower extremity trauma
recommendations. These include level I recommendations:
antibiotics with Gram-positive coverage to start at time
of injury, with the addition of Gram-negative coverage in
Gustilo grade III injuries. Also, high-dose penicillin should
be added in the presence of fecal or possible clostridial con-
tamination. They suggest that aminoglycosides do not offer
an advantage over cephalosporin/aminoglycoside regimens,
and they may have a detrimental effect on fracture healing.
Level II recommendations include discontinuation of antibiot-
ics within 24 h of wound closure (grade I and II fractures) or
72 h postinjury/24 h post soft-tissue coverage in grade III
fractures. A single dose of aminoglycoside is appropriate for
grade II and III fractures.
Anticoagulation
Death from venous thromboembolism (VTE) is prevent-
able, which is why the use of VTE protocols is on the rise.
The prophylaxis of VTE is one of the goals of improved
surgical care identified by the Surgical Care Improvement
Project.73 Victims of major trauma have the highest risk
of VTE.74 Proposed risk factors include spinal cord injury,
lower extremity fractures, pelvic fractures, surgery, femoral
central venous lines, age, immobility, and delay in initiating
thromboprophylaxis.74
Two of the commonly used anticoagulants include unfrac-
tionated heparin (UH) and low-molecular-weight heparin
(LMWH). UH acts on antithrombin, catalyzing the reaction
between antithrombin and thrombin (factor IIa) as well as
factor Xa.75 This inhibits the procoagulant activity of thrombin.
LMWH is a depolymerized form of UH and exerts its action
via factor Xa, with less effect on antithrombin. Until now, few
studies existed comparing the efficacy and safety of pharma-
coprophylaxis using these drugs. One retrospective study
comparing protocols of UH and LMWH found that there was
no difference in incidence of VTE or bleeding complications
between the two drugs and that 5000 U three times a day of
UH was much cheaper than 40 mg per day of LMWH.74
Blood loss
Hemorrhage in the setting of lower extremity trauma is
common, especially with long bone or combined injuries. It
may account for as much as 40% of trauma-related mortality
and is the second leading cause of death after injury.76 As
many as 30% of patients may require massive transfusion
during the initial postinjury period. This is classified as trans-
fusion of 10 or more units of packed red blood cells in the first
24 h following injury.77,78 Unfortunately, there is no ideal
strategy for the management of post-traumatic hemorrhagic
shock. The current trend for prevention of hemorrhagic shock
is a brief “damage control” surgery, rapid fluid resuscitation,
and sufficient administration of blood products. In damage
control surgery, there are four phases: (1) recognizing a patient
who warrants the “damage control” approach; (2) salvage
surgery for control of hemorrhage, contamination, and stabi-
lization of long bone and pelvic fractures; (3) intensive care
unit management for restoration of physiologic and immuno-
logic baseline functions; and (4) scheduled reconstructive
surgeries for definitive management of the injury once the
patient is stable enough.79
The threshold for starting blood transfusion is also debated.
According to ATLS protocols, blood products should be
considered in patients who are non-responders or transient
responders to fluid resuscitation, with estimated blood loss
>30%. The original Transfusion Requirements In Critical Care
(TRICC) trial looking at transfusion protocols provides a
rough estimate of when to transfuse, suggesting that a restric-
tive approach (transfusing when hemoglobin <7 g/dL) may
be safe.80 However, this study population may not be equiva-
lent to a patient involved in lower extremity trauma. It may
be more accurate to follow base deficit and serum lactate in
the assessment of bleeding and shock. Transfusion strategy
also involves multiple components, including red blood cells,
fresh frozen plasma, and platelets. The ratio of each varies
significantly in the literature and is beyond the scope of this
chapter. Additionally, it is important to avoid other factors
that may contribute to coagulopathy, such as hypothermia,
and all attempts should be made to control any such prevent-
able factors.
Outcomes, prognosis, and
complications
Outcomes and prognosis
Functional outcomes
One of the most important criteria of the functional recovery
in patients sustaining lower extremity trauma is their return
to work. Studies have demonstrated that more than one-
quarter of these patients have not returned to work at 1 year
postinjury. Butcher et al.81 investigated functional recovery of
patients who did not return to work by 1 year. Using the
Sickness Impact Profile (SIP) questionnaire, they determined
that return to work occurred in 72% of their patients by 12
months, and 82% had returned to work by 30 months. Among
them, 64% of patients had no disability, 17% had mild dis-
ability, 12% had moderate disability, and 7% had severe dis-
ability. This study did not differentiate between those who
underwent limb salvage and those with amputation.
Mackenzie et al.82 examined functional outcomes in those
patients who underwent amputation following trauma-
related lower extremity injury. Study participants were part
of the original LEAP cohort that had undergone amputation
as a result of their injury. Patients were stratified according to
level of amputation – above-knee, through-knee, and below-
knee. At 24 months, patients with through-knee amputation
had the highest SIP scores. There was a modest degree of
disability among all patient groups. Overall, patients with
through-knee amputation had worse outcomes with lower
self-selected walking speed, ability to perform functional
transfers, and ability to walk and stair-climb. There were
no significant differences in SIP scores between those with
below-knee and those with above-knee amputations.
Amputation versus salvage
A systematic review of outcomes and complications in patients
undergoing reconstruction and amputation of grade IIIB and
IIIC tibial injuries assessed 26 studies in the published litera-
ture.83 It was found that hospital stay was longer in the
amputation group (63.7 vs. 56.9 days), but this was statisti-
cally insignificant. Of those initially reconstructed, the pooled

77
Outcomes, prognosis, and complications
secondary amputation rate was 5.1% in type IIIB fractures and
28.7% in type IIIC fractures. When regressed against the year
of study publication, the secondary amputation rate decreased
– likely due to improved operative technique and increasing
incidence of successful salvage. The rate of osteomyelitis in
limb salvage patients was variable, with a range of 4–56%.
Complete flap loss was 5.8% (pooled result; range 0–15%).
Overall, this study did not reveal a superior strategy in treat-
ing patients with lower limb-threatening injuries, as the out-
comes of salvage and amputation groups were similar.
Patient satisfaction
Very few studies have examined the differences between
patient’s and physician’s satisfaction in lower extremity
trauma. The LEAP study looked at this issue in 463 patients
with unilateral lower extremity injuries. Patients’ satisfaction
was evaluated at 12 and 24 months postinjury via a structured
clinical interview. Surgeons were asked to evaluate their sat-
isfaction with the clinical recovery and cosmetic recovery of
the lower extremity at the 24-month mark. The results dem-
onstrated that there was poor agreement between the
surgeons’ and patients’ satisfaction with both overall and
cosmetic outcomes.84 Surgeons and patients differed particu-
larly on the cosmetic outcome, with patients being less satis-
fied than their surgeons. Patients and surgeons were more
likely to disagree regarding overall outcome when the injury
severity score was greater than 17, complications that required
hospital admission occurred, patients were dissatisfied with
their care, or when patients failed to return to work within 1
year. Disagreement regarding cosmetic outcome was greater
when patients were female, had sustained a traumatic ampu-
tation (patients were more satisfied in this group), had com-
plications requiring hospital admission, or were dissatisfied
with their care. On the whole, 66% of patients were satisfied
with their overall outcome at 2 years, and 34% were not.85 No
pre-existing patient factors were identified to be predictive of
this. The factors that correlated with satisfaction were mea-
sures of physical function, psychological distress, clinical
recovery, and return to work.
Cost-utility
There have been two large studies looking at cost utility in
lower extremity trauma. This is especially important as recon-
structive endeavors are considered not only to be technically
demanding and time-consuming, but they can be associated
with a high risk of complications and rehabilitation time. It is
important to justify this from a patient care and economic
perspective. In 2007, Mackenzie et al.86 conducted a multi-
center study estimating the healthcare costs for 545 patients
with unilateral limb-threatening lower extremity trauma. This
was part of the original LEAP study. They found that, when
costs associated with re-hospitalization and postacute care
were added to the initial cost of hospitalization, the 2-year
overall cost was similar between salvage and amputation
groups. However, when prosthesis-related costs were added,
the amputation group required a much higher cost of treat-
ment, with an initial $10 000 difference in cost and a projected
lifetime cost that was three times higher ($509 275 vs. $163 282)
than the salvage group. In a study by Chung et al.87 a cost-
utility analysis demonstrated that, independently of ongoing
prosthesis-related needs and remaining years of life, amputa-
tion is more expensive overall. They estimated that amputa-
tion will cost a 40-year-old patient $93 606–$154 636 more than
limb salvage. This study suggested that surgeons should
select limb salvage more aggressively, in particular for patients
where amputation is not clearly indicated.
Complications
Wound complications
The goal of reconstruction is to provide soft-tissue coverage
that creates a closed wound, provides vascularized tissue, and
prevents secondary complications of the injury including late
infection and nonunion. A subset of the LEAP study specifi-
cally examined wound complications as stratified by type of
reconstruction. It was found that those reconstructed with free
flaps were more likely to have multicompartment functional
compromise in the leg with more severe soft-tissue injury.
Despite this, there was no overall difference in complication
rates between patients reconstructed with local rotational
flaps and those reconstructed with free tissue transfer.
However, when patients were further stratified by underlying
osseous injury, regression analysis demonstrated that this was
an important predictor of wound complication. In patients
with ASIF/OTA type C injury, those with rotational flap
reconstruction were 4.3 times more likely to have a wound
complication requiring operative intervention than those
with free flap reconstruction.88 Interestingly, there was not an
increased rate of wound complications when the patients
were stratified by time to reconstruction, suggesting that, in
this cohort, time to reconstruction was not an important
predictor, as is suggested by Godina.34
Osteomyelitis
It has been shown that the tibia is the most common site
of infected nonunion and chronic post-traumatic osteomy-
elitis.89 This is associated with morbidity and may be limb-
threatening. In this regard, it is important to prevent the
occurrence of osteomyelitis and treat it early and aggressively.
The LEAP study had an incidence of 7.7% for osteomyelitis,
with 84% of these patients requiring operative intervention
and hospitalization.90
It is thought that an aggregation of microbe colonies
called “biofilm” is the key in the development and persis-
tence of infection.91 The most common organism in chronic
osteomyelitis is Staphylococcus aureus, which may be com-
monly combined with other pathogens such as Pseudomonas
aeruginosa. Four anatomic types of osteomyelitis exist: (1)
medullary (IM bone surface); (2) superficial (bone surface);
(3) localized (full-thickness cortex extending into medullary
canal); and (4) diffuse (circumferential bone involvement).
Furthermore, the patient can be classified according to physi-
ologic status: good systemic defenses (type A), systemic/
local/combined deficiency in wound healing (type B), or
severe local/systemic factors (type C). Infection may be
clinically silent, emphasizing the need for a high index of
suspicion. Diagnosis relies on clinical findings, laboratory
tests (erythrocyte sedimentation rate and C-reactive protein),
diagnostic imaging (X-ray, magnetic resonance imaging, and
technetium-99m bone scan), and, the gold standard, bone

78
SECTION I
CHAPTER 2 • Management of lower extremity trauma
culture. The management of osteomyelitis includes debride-
ment and antibiotics, in conjunction with fracture stabiliza-
tion. It is necessary to remove all operative hardware, debride
infected bony sequestra aggressively, and ream out the IM
canal if rod fixation was used. It cannot be overemphasized
how important it is to perform extensive bony debride-
ment until viable bone with punctate bleeding is achieved.
It is possible to use local antibiotic therapy in the form of
antibiotic-impregnated beads, placed in the defect site follow-
ing debridement. Systemic antibiotic therapy should be broad
initially and tailored according to culture results. If internal
fixation is removed and the fracture is not healed or in a state
of nonunion, a temporary external fixator may be placed until
the infection is eradicated. The secondary stages of recon-
struction involve local or free tissue coverage (usually within
1 week of initial debridement), followed by management of
bony defects or ununited fractures. Bone-grafting procedures
are carried out once the soft-tissue envelope has healed and
infection is under control, typically 6–8 weeks after soft-tissue
coverage.
In some situations amputation is inevitable; these include
extensive bone defects, poor soft-tissue coverage, neurovas-
cular compromise, anticipated poor function, and multiple
comorbidities.91
Nonunion
In the LEAP study, nonunion was among the most common
complications, with an incidence of 23.7%. Of these, 83%
required operative intervention and 72% required inpatient
care.90
Chronic pain
It has long been suspected that chronic pain has been a com-
plication of traumatic injury, but to date there has been little
prospective evidence to document this. The LEAP study
addressed chronic pain in a prospective cohort analysis of
patients with severe lower extremity trauma.92 A total of 397
patients were followed for 7 years after discharge, with a
follow-up rate of 72%. Data were collected regarding injury
and treatment characteristics, socio-demographics, and pre-
dictors of pain. Predictors included functional outcomes
(ambulation, mobility, body care, and communication),
depression and anxiety scores, and pain intensity scores. This
study demonstrated a high level of long-term chronic pain,
with more than one-quarter of the study population reporting
pain that interfered with daily activities and 40% reporting
clinically significant pain intensity. The chronic pain levels in
the study group were comparable to those of back pain and
headache populations at pain clinics. The multivariate analy-
sis did not identify any predictors of pain related to the injury
and treatment, suggesting that the onset of chronic pain is
independent of injury characteristics and surgical treatment
decisions – supporting prior studies by Ashburn and Fine.93
Protective factors included years of education and increased
self-efficiency for return to usual major activities. Risk factors
included alcohol use in the month prior to injury; symptoms
of anxiety, depression, and sleep irregularities at 3 months
postinjury; and, the strongest risk factor, intensity of acute
pain at 3 months postinjury. Narcotic use at 3 months appeared
to be protective as well, perhaps supporting the central sen-
sitization theory for the development of chronic pain.
Secondary procedures
A variety of secondary procedures may be required following
lower extremity reconstruction and limb salvage. These can
fall into two broad categories: (1) secondary cosmetic proce-
dures to improve the quality and appearance of the recon-
struction (e.g., flap debulking); and (2) secondary functional
procedures to finalize the reconstruction (e.g., delayed bone
graft).
Secondary cosmetic procedures
One of the most frequent secondary procedures required to
improve the appearance of the reconstruction is flap debulk-
ing. For fasciocutaneous flap and perforator flaps we prefer
to wait a minimum of 3 months, preferably 6 months prior to
any debulking procedures. Liposuction is the most common
method of debulking. If redundant skin requires excision,
we usually perform this 3 months following liposuction in
order not to compromise vascularity and limit skin excision
to 50% or less of the flap circumference. Combined aggres-
sive liposuction with flap skin excision should be avoided
whenever possible in order to prevent complications. Several
sessions of debulking may be required in certain flaps in
order to provide the lowest profile resurfacing possible, for
example, flaps for medial or lateral malleolus reconstruction
(Figs. 2.35–2.38).
For muscle flaps or myocutaneous flaps, debulking proce-
dures can also be required but less frequently with free muscle
flaps alone. Denervated muscle undergoes significant atrophy
over time and provides excellent contouring for lower-
extremity reconstruction. The skin paddle from a myocutane-
ous flap can also be removed as a split-thickness skin graft or
thin full-thickness skin graft with a dermatome and then
reused to cover the underlying muscle following excision of
excess subcutaneous tissue. If required, the muscle can also
be debulked, and we prefer to use the dermatome for this to
shave the muscle from superficial to deep, making sure to
protect the pedicle at all times. For skin-grafted muscle flaps,
a dermatome can also be used to remove the skin graft from
the flap temporarily. The muscle is then debulked with pro-
gressive shaving using a dermatome, and the skin graft is
recycled to cover the muscle once debulking is completed. We
prefer to use the tourniquet for all debulking procedures,
perform meticulous hemostasis, and use a negative-pressure
dressing to secure the skin graft following debulking (Figs.
2.29A, 2.39 & 2.40).
Secondary functional procedures
Secondary procedures to restore function of the lower extrem-
ity are numerous and include secondary bone graft, hardware
removal or replacement, tendon reconstruction, and nerve
repair/graft. For any anticipated orthopedic procedure, close
collaboration with orthopedic surgery is important in order
to re-elevate the flap safely. Muscle and skin flaps can be
easily re-elevated, although skin flaps provide the greatest
flexibility and ease for re-elevation, which is why we prefer
to use them if secondary procedures are anticipated. The
tourniquet is also used for secondary procedures and eleva-
tion of flaps.

79
Secondary procedures
A
Fig. 2.35  Extensive degloving injury following a motorcycle accident in a 24-year-old man, with exposure of the calcaneus, medial malleolus, and extensor tendons.
B
A
Fig. 2.36  Resurfacing of the lower extremity defect with an extended free anterolateral thigh flap (384 cm2).
B
A
Fig. 2.37  Appearance of the anterolateral
thigh flap following liposuction at 6 months
following initial surgery. A total of 75 cc of
lipoaspirate was removed.
B

80
SECTION I
CHAPTER 2 • Management of lower extremity trauma
Fig. 2.38  A second and final session of flap debulking was performed with liposuction. In this case the flap was aggressively liposuctioned, even in the area of the pedicle,
to minimize bulk. If the peripheral flap incision is kept intact, then aggressive liposuction can be performed while maintaining adequate vascularity.
A
B
C
D
Fig. 2.39  (A,B) Coverage of lower extremity defect with a free gracilis flap and split-thickness skin graft.
A
B

81
Secondary procedures
Fig. 2.40  (A) Despite muscle atrophy, this patient requested further debulking. A
dermatome was first used to remove the split-thickness skin graft, and then used to
debulk the gracilis muscle successively from superficial to deep using a larger
opening. The pedicle location from the previous surgery must be confirmed in
order to protect it at all times, and this secondary procedure is only applicable to
pedicles, which are deep and lying over the defect. (B,C) Once debulking has been
completed to achieve the desired result, the tourniquet is released and meticulous
hemostasis is performed in order to avoid a hematoma under the skin graft.
(D,E) The split-thickness skin graft is then reused to cover the debulked muscle,
and a negative-pressure dressing is applied for 5 days to stabilize the skin graft.
A
B
C
D
E
C
(C) Appearance of the gracilis muscle flap at 3 months following
surgery. Note significant muscle atrophy over time.
Fig. 2.39, cont’d

82
SECTION I
CHAPTER 2 • Management of lower extremity trauma
6. Levin LS. The reconstructive ladder. An orthoplastic approach.
Orthop Clin North Am. 1993;24(3):393–409.
17. Keel M, Trentz O. Pathophysiology of polytrauma. Injury.
2005;36(6):691–709.
22. Management of Complex Extremity Trauma. American College of
Surgeons. The Committee on Trauma. [Online] Available from:
<>.
24. Gustilo RB, Mendoza RM, Williams DN. Problems in the
management of type III (severe) open fractures: a new classification
of type III open fractures. J Trauma. 1984;24(8):742–746.
27. Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment Project
(LEAP) – the best available evidence on limb-threatening lower
extremity trauma. Orthop Clin North Am. 2010;41(2):233–239. An
overview of the LEAP protocol and substudy analyses. A total of 601
patients were enrolled and followed for a period of 44 months at 8 centers.
The LEAP study attempted to assess the characteristics of the patients
sustaining lower extremity injury, environmental characteristics of the
injury, physical and mental aspects of the injury, secondary medical issues
arising from the injury, and functional status. It was found that social,
economic, and personality disadvantages that existed prior to the injury
play a large role in the functional and quality-of-life outcomes measured in
the study. It was also found that the functional outcomes 2 years
postinjury were similar between those undergoing limb salvage and those
that underwent amputation.
29. Ly TV, Travison TG, Castillo RC, et al. Ability of lower-extremity
injury severity scores to predict functional outcome after limb
salvage. J Bone Joint Surg Am. 2008;90(8):1738–1743.
34. Godina M. Early microsurgical reconstruction of complex trauma of
the extremities. Plast Reconstr Surg. 1986;78(3):285–292. Landmark
paper examining the timing of microsurgical reconstruction in extremity
trauma. This study divided patients into 3 groups according to time of
reconstruction: <72 h, 72 h–3 months, >3 months. Godina examined the
incidence of flap failure, infection, bone-healing time, length of hospital
stay, and number of operative procedures. He found that outcomes were
the best in the group reconstructed within 72 h. Those reconstructed
between 72 h and 3 months had the highest rate of infection, and those
reconstructed >3 months postinjury had the longest bone-healing time and
required the greatest number of operations.
40. Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr
Surg. 2010;125(2):582–588. An overview of the management of lower
extremity trauma, including initial management, decision-making for
salvage versus amputation, timing of reconstruction, and choice of flap.
This paper also reviews outcomes of reconstruction, including flap failure,
late complications, and function.
50. Parrett BM, Talbot SG, Pribaz JJ, et al. A review of local and
regional flaps for distal leg reconstruction. J Reconstr Microsurg.
2009;25(7):445–455. A thorough review of local and regional flap options
available in distal leg reconstruction. This paper outlines the preoperative
work-up and provides an algorithmic approach to select an appropriate
flap for reconstruction. Several flaps are reviewed in detail, including their
indications, design, surgical technique, and complications/pitfalls.
82. MacKenzie EJ, Bosse MJ, Castillo RC, et al. Functional outcomes
following trauma-related lower-extremity amputation. J Bone Joint
Surg Am. 2004;86(8):1636–1645. A subset of the LEAP study, 161
patients who underwent above-the-ankle amputation following lower
extremity trauma were followed prospectively for a total of 24 months.
Outcomes included functional measures using the Sickness Inventory
Profile (SIP), pain assessments, and degree of independence assessment.
The SIP was not different between those amputated above- versus
below-the-knee. Physical function was affected by the level of amputation,
with walking speeds higher in below-the-knee amputation patients.
Access the complete reference list online at

82.e1
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Plast Reconstr Surg. 2009;123(4):1245–1255.
54. Zhou G, Zhang QX, Chen GY. The earlier clinic experience of the
reverse-flow anterolateral thigh island flap. Br J Plast Surg.
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55. Komorowska-Timek E, Gurtner G, Lee GK. Supercharged reverse
pedicle anterolateral thigh flap in reconstruction of a massive
defect: A case report. Microsurgery. 2010;30(5):397–400.
56. Follmar KE, Baccarani A, Baumeister SP, et al. The distally based
sural flap. Plast Reconstr Surg. 2007;119(6):138e–148e.
57. Erdmann D, Gottlieb N, Humphrey JS, et al. Sural flap delay
procedure: a preliminary report. Ann Plast Surg. 2005;54(5):562–565.
58. Tan O, Atik B, Bekerecioglu M. Supercharged reverse-flow sural
flap: a new modification increasing the reliability of the flap.
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59. Schoeller T, Huemer GM, Shafighi M, et al. Free anteromedial thigh
flap: clinical application and review of literature. Microsurgery.
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60. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-
assisted closure: a new method for wound control and treatment:
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61. DeFranzo AJ, Argenta LC, Marks MW, et al. The use of vacuum-
assisted closure therapy for the treatment of lower-extremity
wounds with exposed bone. Plast Reconstr Surg.
2001;108(5):1184–1191.
62. Pollak AN. Use of negative pressure wound therapy with
reticulated open cell foam for lower extremity trauma. J Orthop
Trauma. 2008;22(10 suppl):S142–S145.
63. Holt SG, Moore KP. Pathogenesis and treatment of renal
dysfunction in rhabdomyolysis. Intensive Care Med. 2001;27(5):
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64. Loun B, Astles R, Copeland KR, et al. Adaptation of a quantitative
immunoassay for urine myoglobin. Predictor in detecting renal
dysfunction. Am J Clin Pathol. 1996;105(4):479–486.
65. Homsi E, Barreiro MF, Orlando JM, et al. Prophylaxis of acute renal
failure in patients with rhabdomyolysis. Ren Fail.
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66. Stein PD, Yaekoub AY, Matta F, et al. Fat embolism syndrome.
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69. Trisolini R, Cancellieri A, Giovannitti A, et al. Fat embolism may be
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70. Frink M, Hildebrand F, Krettek C, et al. Compartment syndrome
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71. Griffiths DL. The management of acute circulatory failure in an
injured limb. J Bone Joint Surg Br. 1948;30(2):280–289.
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properties of heparin fractionated by affinity chromatography on
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1976;9(6):575–583.
76. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma
outcome: an overview of epidemiology, clinical presentations, and
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77. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation:
directly addressing the early coagulopathy of trauma. J Trauma.
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78. Huber-Wagner S, Qvick M, Mussack T, et al. Massive blood
transfusion and outcome in 1062 polytrauma patients: a prospective
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82. MacKenzie EJ, Bosse MJ, Castillo RC, et al. Functional outcomes
following trauma-related lower-extremity amputation. J Bone Joint
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82.e3
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1989;154(2):86–89.

SECTION I • Lower Extremity Surgery
3 
Lymphatic reconstruction of the extremities
David W. Chang
SYNOPSIS
■ Direct excision with skin grafting is reserved for the most extreme
cases in which function is severely affected.
■ Liposuction for reduction of excess adipose deposition requires lifelong
postoperative compression garments.
■ Reductive procedures alone or as an adjunct are effective in gross
reduction of volume; however, they may carry significant morbidity.
■ Lymphovenous bypass (LVB) appears to be most effective at the early
stages of lymphedema before destruction of lymphatic vessel smooth
muscle and development of irreversible tissue fibrosis.
■ LVB alone may be more effective in addressing the upper extremity vs.
lower extremity lymphedema.
■ Vascularized lymph node transfers (VLNT) can be harvested from
numerous locations such as the groin, axilla, supraclavicular, and
submental regions. They can also be transferred to proximal (groin/
axilla) or distal (wrist/ankle) areas of the affected limb.
■ Harvest of VLNT should be performed carefully to prevent donor limb
lymphedema.
■ VLNT may be combined with LVB in patients with moderate to severe
lymphedema.
Introduction
Lymphedema is a chronic, debilitating disease affecting up to
250 million people worldwide. It is caused by an accumula-
tion of lymphatic fluid leading to progressive tissue fibrosis,
fat hypertrophy, and destruction of lymphatic vessels.1–3
Lymphedema may be classified as primary due to abnormal
development of the lymphatic system or secondary due to
acquired damage to the lymphatic system. Globally, the most
common cause is filariasis, but in the USA and most developed
countries, cancer and its treatments are the most common
cause. There is currently no cure for this disease, and we
are still searching for the “gold” standard treatment for
lymphedema.
Most common and essential treatment for lymphedema is
complex decongestive lymphatic therapy including compres-
sion garments. These therapies are labor intensive, time con-
suming, expensive, and often not covered by insurance. They
also require strict lifetime compliance, which leads to high
rates of non-compliance and patient dissatisfaction. Surgery
may be considered when conservative measures fail. Goals of
surgical intervention include weight reduction of the affected
region, reduced frequency of infections, prevention of disease
progression, improvement in limb function and cosmesis, and
overall improvement in patient’s quality of life.
Evaluation techniques
There are many modalities in place to evaluate lymphedema.
The International Society of Lymphology has created a clinical
staging system to help document disease progression. In stage
I, the limb is swollen, feels heavy, and has pitting edema
partially reversible with elevation. In stage II, the limb is
swollen, the skin is brawny, and tissue fibrosis has started,
leading to non-pitting edema that is not reversible with eleva-
tion. In stage III, there is enormous swelling of the involved
extremity with fibrosis and hardening of the dermal tissues.
Skin papillomas, acanthosis, fat deposits, and warty over-
growths may be present.
Currently, the most definitive tool for evaluation of lymph-
edema is lymphoscintigraphy, in which a radioactive dye is
injected into the affected limb to visualize the lymphatics
and quantify the lymphatic flow by calculating a lymphatic
transport index. The index ranges from 0 (optimal flow) to 45
(no flow). A transport index below 10 is considered normal.
Indocyanine green (ICG) lymphangiography is a newer
technology to help us visualize superficial lymphatics and
determine the severity of the disease. ICG is a fluorescent dye
that is activated when it binds to protein and imaged using
near-infrared technology. A staging system has been proposed
based on ICG lymphangiography findings.4 In stage I, there
are many patent lymphatic vessels, with minimal, patchy
  Access video content for this chapter online at expertconsult.com

84
SECTION I
CHAPTER 3 • Lymphatic reconstruction of the extremities
infections, skin ulcerations, chronic pain, and poor quality of
life, radical excision may be their only, and possibly best,
option for returning to function (Fig. 3.1).
Liposuction
The accumulation of lymphatic fluid in the limb results in
increased deposition and hypertrophy of the adipose tissue.
Liposuction, in which a fenestrated metallic cannula con-
nected to vacuum suction is used to aspirate subcutaneous
fat, was originally developed for body contouring but since
then has been used for the treatment of lymphedema. O’Brien
et al. reported an average of 20–23% reduction using liposuc-
tion to treat lymphedema for a mixed cohort of patients.11
Brorson and Svensson compared the combined use of liposuc-
tion and compression therapy to therapy alone in stage II
patients and reported 115% reduction in volume compared to
54%. This was maintained at 4 years with average reduction
of 106% (66–179%).12
One of the theoretical risks of liposuction is further damage
to existing lymphatic vessels. Cadaveric and imaging studies
have shown that performing liposuction longitudinally to the
limb minimizes this damage and that further impairment to
already delayed transport of lymphatic fluid does not seem
to occur.13–15 In addition to volumetric reduction, functional
improvement was also reported by Qi et al. when liposuction
was combined with physiologic treatments. The incidence of
cellulitis (6.5 ± 4.3 vs. 0.7 ± 0.8 episodes/year) was drastically
improved albeit confounded by the mixture of procedures
performed.16
In general, treatment of lymphedema with circumferential
liposuction is considered safe with quick recovery within
48 h.17 Complications are few and usually limited to minor
wound healing problems and paresthesias. The use of tumes-
cence and tourniquets during liposuction can greatly decrease
the blood loss and need for transfusions.
While liposuction can aggressively debulk hypertrophied
adipose tissue in the lymphedematous limb, the primary
disadvantage of liposuction is the lifelong need for continu-
ous (24 h) use of compression garments postoperatively to
maintain the new equilibrium.18 In the Brorson series, patients
that discontinued use of compression garments rapidly
re-accumulated fluid.12
Physiologic treatment
Another approach to surgically treat lymphedema is to create
a new path for lymphatic drainage or repair the lymphatic
dysfunction. This concept was first described by Kondoleon
in 1912 and expounded upon by Sistrunk in 1927 where they
sought to establish new pathways between the deep and
superficial systems.19–21 Sistrunk removed skin and soft tissue
through an elliptical incision along the medial arm and wide
excision of the deep fascia. Thompson expanded this proce-
dure by embedding the de-epithelialized skin flaps from the
entire length of the elliptical incision along the neurovascular
bundle. The theory was to facilitate spontaneous lymphan-
giogenesis from the superficial system that can be drained
away by the deep system. Although some have reported
favorable results with these methods, there have been no
objective data that demonstrates lymphangiogenesis via this
approach.22
dermal backflow. Stage II shows a moderate number of patent
lymphatic vessels, with segmental dermal backflow. Stage III
shows few patent lymphatic vessels, with extensive dermal
backflow involving the entire extremity. Stage IV shows
no patent lymphatic vessels, with severe dermal backflow
involving the entire extremity. Knowing the lymphedema
disease stage helps guide appropriate surgical interven-
tion. Postoperatively, one of the most common and simple
methods to determine improvement is to perform serial cir-
cumferential measurements or limb volumes. Other means to
measure outcomes include bio-impedance and quality-of-life
questionnaires.
Surgical management
Options for surgical treatment of lymphedema can be divided
into two categories: excisional and physiologic treatment.
Excisional treatment usually involves reductive procedures
such as liposuction and excisional debulking with skin graft-
ing (Charles procedure). Physiologic treatment is aimed at
restoring or reconstructing the physiologic drainage of the
lymph fluid. Several different strategies to achieve this have
been proposed, such as buried flaps, direct repair of lymphat-
ics, bypass grafting of lymphatics, lymphaticovenular anasto-
mosis, and vascularized lymph node transfers. The outcomes
of such procedures vary. The aim of this chapter is to present
the overview of therapies that have been described and tested.
Reductive/excisional techniques
Direct excision (Video 3.4 )
In 1912, Charles wrote a book chapter entitled “Elephantiasis
Scroti” in which he described a treatment for scrotal lymph-
edema that he learned while spending time in Calcutta with
his mentor McLeod. This procedure involved excision of the
lymphedematous scrotal tissue and coverage with thigh
advancement flaps. Charles suggested this technique could be
applied to treat lymphedema in other areas of the body
including the lower extremities, but would require preopera-
tive arrangements for skin graft coverage.5,6 This idea of
treating lower extremity lymphedema with radical excision
down to deep fascia and covering with a skin graft was not
actually reported until 1940, when Macey from the Mayo
Clinic published his experience. What we currently consider
the “Charles procedure” was reported in 1947 by Poth from
Galveston, who reported utilizing the skin from the excised
specimen to cover the exposed limb.7,8
Although some have advocated the abandonment of such
procedures, there are some cases of severe refractory lymph-
edema that have been successfully treated with radical exci-
sion and skin grafting.9,10 Undoubtedly, although this can be
an effective way of reducing bulk and allowing function of
some extremities, there are also significant risks. In addition
to contour irregularities, scarring, and poor cosmesis, there
are risks of infection, hematoma, blood loss requiring transfu-
sions, and possible loss of skin grafts resulting in more surgery.
Alternatively, staged elliptical excision of skin and subcutane-
ous tissue can also be performed to minimize morbidity or to
address specific pockets of tissue. For some patients suffering
with severe impairment in use of their limb, recurrent

85
Surgical management
A
B
C
D
E
F
Fig. 3.1  An example of Charles procedure. Skin and subcutaneous lymphedematous tissue is excised to the deep fascia. Skin graft can be harvested from the specimen or
contralateral thigh and used to cover the defect. Patient’s remark in her letter, “My first hiking/outing in 13 years. My first pair of jeans in 13 years and in 14 years a pair of
new balance sneakers.” (From: Cheng MH, Chang DW, Patel K. Principles and Practice of Lymphedema Surgery. New York: Elsevier; 2015.)

86
SECTION I
CHAPTER 3 • Lymphatic reconstruction of the extremities
bypasses in upper and lower extremities when LVB could not
be performed.32 In their procedure, multiple distal lymphatic
channels are sutured into the cut distal end of an autologous
vein graft that provides a conduit to more proximal lymph
vessels inserted into the other end of the vein graft. Patients
were followed for as long as 5 years demonstrating improve-
ment in edema and function.
Lymphovenous bypass (LVB) and lymphovenous
anastomosis (LVA) (Videos 3.1 and 3.3 )
The final destination of lymphatic fluid in the lymph vessels
is return to the venous system by way of the thoracic ducts.
LVB attempts to return the lymphatic fluid to the venous
system earlier along the pathway. A lymphovenous shunt was
first described by Jacobson in 1962 in a canine model.33 This
was followed by Yamada who first experimented in dogs
before applying the technique in a series of patients with
lower extremity lymphedema.34 In cases involving filariasis,
Sedlacek described the use of end-to-side LVB using the
saphenous vein.35 While others also used the saphenous vein,
concern over venous hypertension in larger caliber vessels
resulted in attempts to bypass to venules. Yamada was the
first to describe end-to-end anastomosis between a lymphatic
and venule, hence LVA. The use of “supermicrosurgery” to
anastomose vessels <0.8 mm in diameter has recently gained
popularity around the world.4,36–38,39
Results of LVB have been favorable, but outcomes have
been difficult to standardize. In 1990 O’Brien et al. reported
long-term follow-up on 90 patients, some of whom received
LVB-only and others who had LVB with adjunctive reductive
procedures.40 In the cohort that received LVB-only, subjective
improvement occurred in 73% of patients and objective
improvement was documented in 42% of patients with an
average of 44% reduction in volume. At 4-year follow-up, 74%
of patients were able to discontinue conservative measures
completely and the incidence of cellulitis decreased by 58%.
Results with LVA operations have likewise been difficult to
generalize with a wide range of results, differing follow-up
times, variable postoperative therapy protocols, non-standard
volumetric measurements, and no metrics on patient out-
comes. Subjective measures of improvement have ranged
from 95% to 50% of patients. Variable volumetric improve-
ments have ranged from 75% decrease in 73% of patients to
no change in 50% of patients, with average reduction in
volume of 55%.4,36,41–43 In the few studies that included inci-
dence of cellulitis, most demonstrated a significant decrease
after LVA/LVB.36,40,44 Finally, a portion of patients were able to
completely discontinue use of compression garments even
over long-term follow-up.36
In a recent report of the author’s experience with 100
patients undergoing LVA (89 upper extremity and 11 lower
extremity), symptom improvement was reported in 96% of
patients and quantitative improvement was noted by 74%.
The overall mean volume differential reduction at 12 months
follow-up was 42%. This reduction was significantly larger in
patients with earlier stage (stage I or II) vs. later stage (stage
III or IV) lymphedema as determined with ICG (61% vs.
17%).4 LVB alone is best indicated in patients with mild to
moderate upper extremity lymphedema where there are still
some functioning lymphatic vessels and there is minimal
tissue fibrosis.
Flap interposition
The basis behind flap interposition is to place functioning
lymphatic vessels contained within a segment of vascularized
tissue into an affected area to siphon or bypass excess lymph
fluid. In 1935, Gilles and Fraser were the first to treat lower
extremity lymphedema by attaching a flap of skin and subcu-
taneous tissue from the arm to the leg and keeping the arm
by the patient’s side.23,24 In the second stage, the flap was
divided and the flap was transferred to the trunk. The theory
was to use the flap from the arm to re-establish lymphatic flow
and then to eventually bypass the groin region and restore
lymphatic flow to the trunk.
Goldsmith et al. reported the use of greater omentum flaps
to upper and lower extremity lymphedema.25 The greater
omentum was pedicled off the ipsilateral gastroepiploic vessel
and transferred to the extremity via a subcutaneous tunnel.
The excess lymph fluid in the extremity was expected to drain
into the abdominal lymphatic system through the rich network
of lymph vessels in the greater omentum. In the series of 22
patients, 38% of lower extremity and 56% of upper extremity
experienced good results. Despite this moderate improve-
ment, the operation did not gain popularity due to the high
incidence of complications including bowel obstruction, pul-
monary embolus, and hernia.
Since then other authors reported small series using a
variety of pedicled, free muscle, and myocutaneous flaps
(tensor fascia lata, deltopectoral, latissimus, and serratus) for
the treatment of extremity and head and neck lymphedema.26–29
No prospective or long-term studies have demonstrated the
efficacy of these procedures, and they remain anecdotal for
the most part.
Lymphatic–lymphatic bypass
Some investigators have attempted to bypass fibrosed lym-
phatics by using lymphatic or vein grafts to link distal lym-
phatics to more proximal lymphatic channels. Baumeister and
Suida attempted to bridge areas of stenosed lymphatic vessels
with autologous lymphatic grafts in the upper and lower
extremities.30 For the upper extremity, healthy lymphatic
vessels from the medial thigh are harvested as a composite
graft and buried in a subcutaneous tunnel between the supra-
clavicular shoulder region and the upper arm. The lymphatic
vessels at either end are microscopically identified and anas-
tomosed to the recipient lymphatics. To treat unilateral lower
extremity lymphedema, the lymphatics of the graft spans
across the affected thigh and the contralateral groin region. In
55 patients tested, there was an 80% reduction of volume at
3-year follow-up. The patency of the lymphatic grafts were
tested with lymphoscintigraphy and demonstrated new
lymphatic drainage patterns and 30% faster clearance of
radioisotope than in preoperative images. Ho and colleagues
performed similar procedures and noted that the microlym-
phatic bypass must be carried out before the lymphatics were
permanently damaged by back-pressure and recurrent infec-
tion.31 In addition to the drawback of long incisions at donor
and recipient sites, the harvest of lymphatics from a functional
extremity may predispose that extremity to lymphedema.
Alternatively, vein grafts have been used to perform distal
to proximal lymphatic bypasses. Campisi et al. reported a
series of 39 patients using lymphatic–venous–lymphatic

87
Surgical management
performed. After completion of the anastomosis, patency can
be confirmed with isosulfan blue passing from the lymphatic
to the venule, or with ICG lymphangiography.
The following is the author’s preferred method for LVA.
After the patient is anesthetized, ICG is injected into the
dermis of the webspace and superficial lymphatics are evalu-
ated with near-infrared fluorescence (Fig. 3.3). Dissection is
performed under the microscope in the superficial subcutane-
ous plane to locate a good venule and lymph channel. Lym-
phatics are confirmed with isosulfan blue and ICG. Once a
bypass site is determined, the lymphatic is anastomosed to
the venule either end-to-side or end-to-end depending on the
vessel size match (Fig. 3.4). After the anastomosis is complete,
the patency is confirmed with isosulfan blue and ICG (Fig.
3.5). The incision is closed under the microscope as well to
ensure no damage to the delicate superficial anastomosis.
Postoperatively the patient’s limb is wrapped by the lymph-
edema physical therapist. Wrapping is performed in lieu of
compression garments for about 1 month postoperatively to
avoid shear injury to the delicate anastomoses.4
Most reported series of lymphatic bypass surgery have
reported low complications rates, primarily consisting of
minor wound healing problems and cellulitis.4,40,42,50 Most
cases of wound healing problems healed spontaneously, and
cases of cellulitis were treated with a short course of antibiot-
ics. In general LVA may be best indicated in patients with mild
upper extremity lymphedema who still have a moderate
amount of functioning lymphatic vessels and minimal irre-
versible tissue fibrosis.4
Vascularized lymph node transfers (VLNT)
(Video 3.2 )
Another approach to treating lymphedema is to replenish the
missing lymph nodes of the affected extremity by harvesting
healthy lymph nodes from one area of the body and
In a subsequent study, skin tissue changes in patients
before and after LVB were analyzed to assess whether these
procedures can reverse the pathologic tissue changes associ-
ated with lymphedema.45–47 Biopsy specimens were fixed and
analyzed for inflammation, fibrosis, hyperkeratosis, and lym-
phangiogenesis. Histologic analysis demonstrated a significant
decrease in tissue CD4+ cell inflammation in lymphedematous
limb (but not normal limb) biopsies (p < 0.01). These changes
were associated with significantly decreased tissue fibrosis
as demonstrated by decreased collagen type I deposition and
transforming growth factor-β1 (TGF-β1) expression (p < 0.01).
In addition, we found a significant decrease in epidermal
thickness, decreased numbers of proliferating basal keratin-
ocytes, and decreased numbers of LYVE-1 + lymphatic vessels
in lymphedematous limbs after LVB. We have shown, for the
first time, that microsurgical LVB not only improves symptom-
atology of lymphedema but also helps to improve pathologic
changes in the skin. These findings suggest that some of the
pathologic changes of lymphedema are reversible and may be
related to lymphatic fluid stasis.
Recent technological advancements with fluorescence
lymphangiography have provided surgeons with much better
ability to perform real-time identification and evaluation of
existing lymphatics.48,49 Injection of ICG dye into the dermis
and evaluation with near-infrared laser angiography immedi-
ately displays the severity of the process and location of
vessels if present (Fig. 3.2). In early stage disease, it is easy to
identify discrete functioning lymphatic channels. In late stage
disease significant dermal backflow is present. This improves
operative efficiency and allows for limited dissection and
morbidity to the patient, as well as quicker recovery. The
surgery is then performed using short horizontal incisions at
the marked locations along the length of the extremity. Dis-
section is performed at the superficial subcutaneous plane
to locate a venule and lymphatic channel, confirmed with
isosulfan blue or ICG lymphangiography, and the LVA is
Fig. 3.2  Lymphedema classification based on
indocyanine green lymphangiographic findings.  
(A) Stage I: many patent lymphatic vessels, with
minimal, patchy dermal backflow. (B) Stage II:
moderate number of patent lymphatic vessels, with
segmental dermal backflow. (C) Stage III: few
patent lymphatic vessels, with extensive dermal
backflow involving the entire arm. (D) Stage IV: no
patent lymphatic vessels seen with severe dermal
backflow involving the entire arm and extending to
the dorsum of the hand. (From: Chang DW, Suami
H, Skoracki R. A prospective analysis of 100
consecutive lymphovenous bypass cases for
treatment of extremity lymphedema. Plast Reconstr
Surg. 2013;132(5):1305–1314.)
A
B
C
D

88
SECTION I
CHAPTER 3 • Lymphatic reconstruction of the extremities
vascular supply during transfer results in greater improve-
ments in the degree of edema and in lymphatic function.56
In 1982, Clodius first reported the use of VLNT in humans
for treatment of lower extremity lymphedema in two patients.
In the first patient, a pedicled groin flap including the inguinal
lymph nodes was transferred to the contralateral inguinal
region of the affected lower extremity resulting in a stable
volume reduction. In the second patient, a free groin flap was
transferred to the medial knee to bridge a lymphatic defect
caused by trauma. This patient initially experienced limb
volume reduction, but his lymphedema recurred within 6
months postoperatively.20 Since then, many surgeons have
worked at perfecting the technique. In 2006, Becker reported
favorable long-term outcomes in 24 patients who underwent
free transfer of nodes from the groin to either the axilla or
elbow of the affected upper extremity, including objective
evidence of functioning transplanted lymph nodes with
lymphoscintigraphy in 30% of the patients.57
The harvest of vascularized lymph nodes has been
described using groin, thoracic, submental, supraclavicu-
lar nodes, and omentum. The lymph nodes in the groin
have been described as being spread over five regions –
central (saphenofemoral junction), superomedial, superolat-
eral, inferomedial, and inferolateral.58 Since nodes that drain
the lower limb are located medially and centrally, it is more
advisable to harvest the laterally based nodes that drain the
suprailiac region. The superior row of nodes is supplied by
the superficial circumflex iliac artery, whereas the medial
column is supplied by branches off the femoral artery.59,60
Although controversy exists regarding the safety for harvest-
ing medial nodes, there is agreement in preserving the deeper
lymphatics and nodes inferior to the inguinal ligament,
and many have advocated using the reverse sentinel node
mapping technique to avoid causing secondary donor site
lymphedema.
Fig. 3.3  Indocyanine green (ICG) lymphangiography is performed by intradermal injection of ICG into each finger/toe web of the lymphedematous limb. An infrared camera
(A,B) is used to visualize and mark the visible lymphatic pathways (C,D). (From: Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous
bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013;132(5):1305–1314.)
A
B
C
D
Fig. 3.4  The lymphatic vessel is anastomosed to the venule either end-to-side or
end-to-end depending on the vessel size match.
transplanting them as a free tissue transfer to either the
affected basin or a non-anatomic area on the affected limb. It
is unclear whether the orthotopically placed lymph nodes act
as a sponge to absorb lymphatic fluid and direct it into the
vascular network, or if the transferred nodes induce lymphan-
giogenesis, or perhaps both.51–53 Although some researchers
have experimented in animal models with grafting avascular
whole nodes or cut up lymph nodes, their viability is highly
variable.54,55 In general, it has been shown that preserving the

89
Surgical management
Cheng et al. described the use of submental lymph nodes
based off the submental branch of the facial artery, taking care
to avoid injury to the marginal mandibular branch. The author
has advocated for the use of supraclavicular nodes based off
the transverse cervical artery (Fig. 3.7).64 Dissection of this flap
can be tedious as there is frequent anatomic variation, and
care must be taken to avoid injury to the lymphatic ducts.
Additionally, while a skin paddle can be included in the flap
design, its vascularity is not always reliable.
The other consideration when performing this surgery is
where to place the transplanted tissue in the affected limb:
anatomic vs. non-anatomic. The theory behind placement in
non-anatomic sites is that they work as a “lymphatic pump”.
Pulsations from the arterial anastomosis act as a pump pro-
viding a strong hydrostatic force into the flap and then the
low-pressure flap vein acts as suction. Since lymph has lower
colloid osmotic pressure than blood, lymphatic fluid is drawn
into the capillaries. It is also theorized that a “catchment”
effect is at play with non-anatomic placement as well. Distal
flap placement allows gravitational drainage of the limb, and
as interstitial pressures normalize old lymphatic channels
may open allowing improved lymphatic drainage. Proponents
of non-anatomic placement also believe it is better to avoid
the scarred bed present in anatomic placement. A disadvan-
tage to non-anatomic placement is the presence of a visible,
bulky flap on the extremity. It also is commonly difficult to
primarily close the recipient site due to compression on the
pedicle and skin grafts are often needed. The advantages of
anatomic placement are excision of scar tissue, which is likely
contributing to the lymphedema and placement of healthy
vascularized lymph nodes to promote lymphangiogenesis
where lymphatics are known to be deficient. Additionally
there is abundant surrounding soft tissue to allow easy closure
and the scar is usually well hidden. In the upper extremity,
vascularized lymph nodes have been placed in the axilla,
elbow, or wrist. In the lower extremity, vascularized lymph
nodes have been placed in the ankle, knee, or groin.63
In treating upper extremity lymphedema, recipient sites
have included the wrist, elbow, and axillary regions. As most
upper extremity lymphedema results from prior surgery with
or without radiation to the axilla, it is important to perform
wide excision of the scar that may be enveloping nerves,
muscles, and recipient vessels (e.g. thoracodorsal), to both
ensure a healthy bed for lymphangiogenesis and to remove
scar that would prevent bridging of lymphatics in the recipi-
ent bed. Becker et al. reported treating upper extremity
Saaristo combined vascularized lymph node transfer with
autologous breast reconstruction and also reported favor-
able outcomes, with one-third of patients no longer needing
compression therapy and evidence of improved lymphatic
flow on lymphoscintigraphy in five of six cases.61 The lateral,
superficial groin lymph nodes are harvested for transfer
leaving behind the deeper lymph nodes that drain the leg.
The desired nodes are usually located deep to Scarpa’s fascia
within a 3 cm radius of a point 3 cm inferior and perpendicu-
lar to a point one-third the distance from the pubic tubercle
to the anterior superior iliac spine, clustered at the junction
of the superior inferior epigastric and superficial circumflex
iliac veins. Reverse lymphatic mapping with technetium and
ICG is performed to decrease the risk of causing donor site
lymphedema. In combined breast reconstruction cases, this
tissue is taken as an extension of the abdominal tissue based
on the deep inferior epigastric system used to reconstruct
the breast (Fig. 3.6). In these cases, the superficial circumflex
iliac vein is anastomosed in the axilla in addition to the
arterial and venous anastomosis of the deep inferior epigas-
tric vessels to the internal mammary vessels for the breast
reconstruction.62,63
Fig. 3.5  The patency of the bypass is
confirmed by observing the isosulfan
blue dye pass from the lymphatic
through the anastomosis into the
venule (A). Alternatively, indocyanine
green (ICG) may be also be used if the
operating microscope has capability for
ICG fluoroscopy (B). (From: Chang
DW, Suami H, Skoracki R. A
prospective analysis of 100 consecutive
lymphovenous bypass cases for
treatment of extremity lymphedema.
Plast Reconstr Surg.
2013;132(5):1305–1314.)
A
B
Fig. 3.6  An example of a free deep inferior epigastric perforator flap with lymph
node flap based on superficial circumflex iliac artery for simultaneous breast
reconstruction and lymph node transfer.

90
SECTION I
CHAPTER 3 • Lymphatic reconstruction of the extremities
Fig. 3.7  A supraclavicular lymph node transfer
based off the transverse cervical artery. (From:
Cheng MH, Chang DW, Patel K. Principles and
Practice of Lymphedema Surgery. New York:
Elsevier; 2015.)
Inferior thyroid
artery
External
jugular vein
Transverse
cervical artery
Fig. 3.8  A woman with lymphedema of her right arm for 5 years following right
mastectomy and radiation therapy. Her right arm is 81% larger than her left arm.
lymphedema by transferring inguinal lymph nodes to the
axillary region.57 The anterior recurrent ulnar artery and
basilica vein or the radial artery and its vena comitantes have
been used by Cheng and Gharb as recipient vessels at elbow.59,60
In contrast, the radial artery at the level of the wrist has been
used by Lin et al., as recipient vessels for groin nodes based
off the superficial circumflex iliac vessels.65
For the lower extremity, the ankle and groin are the most
common recipient sites. Similar to the axilla, the groin may
often require extensive lysis or excision of scars from previous
surgery and radiotherapy.51,64,66 The use of the ankle for recipi-
ent site in the lower extremity follows along the logic that the
gravitational forces that keep the lymphatic fluid from rising
up to the groin are difficult to overcome.64,66 Instead placement
of the vascularized lymph nodes at the level of the ankle
would take advantage of these forces to facilitate drainage
into the flap at the level of the ankle.
For isolated extremity lymphedema, the author tends to
harvest the supraclavicular nodes and place the tissue in the
anatomic location. It is important to excise all scar in the
recipient site as it hinders lymphatic flow and inhibits lym-
phangiogenesis. If it is difficult to access or remove scar in the
anatomic location, the author’s preference is to place the
vascularized lymph nodes just distal on the limb to the site of
lymphatic obstruction. For example, in a patient who had
removal of pelvic lymph nodes via laparotomy, the flap would
be placed in the proximal thigh along the femoral artery and
saphenous vein. Additionally, if a patient has no definitive site
of injury or primary lymphedema with edema localized to the
distal limb, the author prefers to place lymph nodes at the
medial portion of the leg along the posterior tibial vessels as
opposed to the dorsum of the ankle. This results in a less
bulky flap and allows better ease in wearing shoes.
A recent meta-analysis looked at five quantitative studies
reporting outcomes with vascularized lymph node transfer.
One of these studies provided level III evidence, and the
remaining were level IV. Subjective improvement was reported
by 100% of patients, 91% had a quantitative improvement,
and 78% were able to discontinue compression therapy.
Complications included infection (8%), lymphorrhea (15%),
re-exploration (3%), and need for additional procedures
(36%).19 As mentioned previously, although helpful in sum-
marizing outcomes, these results should be interpreted with
scrutiny given the great amount of heterogeneity between the
studies. The largest series included in the meta-analysis was

91
Surgical management
Fig. 3.9  Preoperative indocyanine green lymphangiography shows severe
lymphatic dermal backflow in the hand and patent lymphatic vessels at the elbow.
Fig. 3.10  A vascularized lymph node
transfer to the axilla and four
lymphovenous bypasses were
performed on the arm. Lymphazurin
and Indocyanine Green (ICGN)
demonstrate patency of one of the E–S
anastomosis.
A
B
C
from Becker who reported experience with 24 patients.21 Since
then, that group has reported operating on 1500 patients with
an average 3-year follow-up, and they have briefly commented
on their outcomes, although they have not published detailed
results. They reported 98% of patients have some degree of
improvement, with 40% of clinical stage I or II patients expe-
riencing normalization of their affected extremity.24
While the literature for vascularized lymph nodes is still in
its early stages, results have been favorable with an average
volume reduction of 47%.43,63 The indications for VLNT are
still unclear, but some have advocated criteria based on total
occlusion on lymphoscintigraphy, international society of
lymphedema stage II with repeated episodes of cellulitis, no
acute cellulitis, and more than 12-months of follow-up.59
Fig. 3.11  At 12 months, her right arm had 57% reduction in excess volume.
VLNT offers an exciting new horizon for physiologic treat-
ment of more advanced stage lymphedema. Furthermore,
for patients with moderate to severe lymphedema, combining
both VLNT and LVA may optimize the chances for improve-
ment of lymphedema as these two approaches work via
different mechanisms. VLNT is done proximally and LVA
is done distally to take advantage of both procedures
(Figs. 3.8–3.11).

92
SECTION I
CHAPTER 3 • Lymphatic reconstruction of the extremities
Prophylactic surgery
As we have gained more experience with lymphatic surgery,
the idea of prophylactic surgery has been proposed. Boccardo
et al. have proposed a procedure named lymphatic microsur-
gical preventing healing approach (LYMPHA). This involves
anastomosing arm lymphatics to a collateral branch of the
axillary vein at the time of nodal dissection to prevent lymph-
edema. They have reported 4-year outcomes in 74 patients
undergoing this procedure, and only 3 patients have devel-
oped lymphedema determined by volumetry and lymphos-
cintigraphy.26 This 4% risk of lymphedema compares favorably
to the 13–65% incidence of lymphedema in women undergo-
ing axillary lymph node dissection. Although these results are
intriguing, further study needs to be performed before this
can truly be determined to be efficacious or oncologically safe.
4. Chang DW, Suami H, Skoracki R. A prospective analysis of 100
consecutive lymphovenous bypass cases for treatment of extremity
lymphedema. Plast Reconstr Surg. 2013;132(5):1305–1314. In a recent
report of the author’s experience with 100 patients undergoing LVA,
symptom improvement was reported in 96% of patients and quantitative
improvement was noted by 74%. The overall mean volume differential
reduction at 12 months follow-up was 42%. This reduction was
significantly larger in patients with earlier stage (stage I or II) vs. later
stage (stage III or IV) lymphedema as determined with indocyanine green
(61% vs. 17%). Lymphovenous bypass alone is best indicated in patients
with mild to moderate upper extremity lymphedema where there are still
some functioning lymphatic vessels and there is minimal tissue fibrosis.
39. Koshima I, Kawada S, Moriguchi T, Kajiwara Y. Ultrastructural
observations of lymphatic vessels in lymphedema in human
extremities. Plast Reconstr Surg. 1996;97(2):397–405. Koshima biopsied
lymphatic trunks and demonstrated that the proximal-to-distal destruction
of the endothelial and smooth muscle cells within the tunica media is a key
step for lymphedema progression. Clinical experiences have been consistent
with Koshima’s findings in that subdermal lymphatic vessels are easily
identifiable at the distal arm but much more difficult to identify in the
proximal arm.
42. Chang DW. Lymphaticovenular bypass for lymphedema
management in breast cancer patients: a prospective study. Plast
Reconstr Surg. 2010;126(3):752–758.
47. Ghanta S, Cuzzone D, Torrisi J, et al. Lymphaticovenous bypass
decreases pathologic skin changes in upper extremity breast
cancer-related lymphedema. Lymphat Res Biol. 2015;13(1):46–53. In
this study, it was demonstrated for the first time that microsurgical LVB
not only improves symptomatology of lymphedema but also helps to
improve pathologic changes in the skin. These findings suggest that some
of the pathologic changes of lymphedema are reversible and may be related
to lymphatic fluid stasis.
49. Suami H, Chang DW, Yamada K, Kimata Y. Use of indocyanine
green fluorescent lymphography for evaluating dynamic lymphatic
status. Plast Reconstr Surg. 2011;127(3):74e. Recent technological
advancements with fluorescence lymphangiography have provided
surgeons with much better ability to perform real-time identification and
evaluation of existing lymphatics. 12 ICG dye into the dermis and
evaluation with near-infrared laser angiography immediately displays the
severity of the process and location of vessels if present. This improves
operative efficiency and allows for limited dissection and morbidity of the
patient, as well as quicker recovery.
57. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy
lymphedema: long-term results following microsurgical lymph
node transplantation. Ann Surg. 2006;243(3):313–315.
61. Saaristo AM, Niemi TS, Viitanen TP, et al. Microvascular breast
reconstruction and lymph node transfer for postmastectomy
lymphedema patients. Ann Surg. 2012;255(3):468–473. Saaristo
combined vascularized lymph node transfer with autologous breast
reconstruction and also reported favorable outcomes, with one-third of
patients no longer needing compression therapy and evidence of improved
lymphatic flow on lymphoscintigraphy in five of six cases. The lateral,
superficial groin lymph nodes are harvested for transfer leaving behind the
deeper lymph nodes that drain the leg.
62. Ngyuen A, Chang EI, Suami H, Chang DW. An algorithmic
approach to simultaneous vascularized lymph node transfer with
microvascular breast reconstruction. Ann Surg Oncol.
2015;22(9):2919–2924.
64. Althubaiti GA, Crosby MA, Chang DW. Vascularized
supraclavicular lymph node transfer for lower extremity
lymphedema treatment. Plast Reconstr Surg. 2013;131(1):133e–135e.
65. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node
transfer using the wrist as a recipient site for management of
postmastectomy upper extremity lymphedema. Plast Reconstr Surg.
2009;123(4):1265–1275.
Access the complete reference list online at

Summary
The surgical treatment of lymphedema has been attempted
since the early 20th century. This has obviously been a difficult
problem to solve for surgeons and an even more difficult
problem for the patients who are afflicted. Recent technologi-
cal advances have enabled surgeons to refine previous tech-
niques and develop new ones. Despite variability in protocols
and reported outcomes, LVA and VLNT offer promising solu-
tions for the future. In general, early intervention before the
development of lymphatic fibrosis and adipose deposition
results in improved final outcomes. Consensus in grading
systems, reporting of outcomes, and standardized protocol
will help to facilitate the next phase of evolution in the treat-
ment of lymphedema.

92.e1
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55. Hadamitzky C, Blum KS, Pabst R. Regeneration of autotransplanted
avascular lymph nodes in the rat is improved by platelet-rich
plasma. J Vasc Res. 2009;46(5):389–396.
56. Tobbia D, Semple J, Baker A, et al. Experimental assessment
of autologous lymph node transplantation as treatment of
postsurgical lymphedema. Plast Reconstr Surg. 2009;124(3):
777–786.
57. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy
lymphedema: long-term results following microsurgical lymph
node transplantation. Ann Surg. 2006;243(3):313–315.
58. van der Ploeg IM, Kroon BB, Valdes Olmos RA, Nieweg OE.
Evaluation of lymphatic drainage patterns to the groin and
implications for the extent of groin dissection in melanoma patients.
Ann Surg Oncol. 2009;16(11):2994–2999.
59. Cheng MH, Chen SC, Henry SL, et al. Vascularized groin lymph
node flap transfer for postmastectomy upper limb lymphedema:
flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg.
2013;131(6):1286–1298.
60. Gharb BB, Rampazzo A, Spanio di Spilimbergo S, et al.
Vascularized lymph node transfer based on the hilar perforators
improves the outcome in upper limb lymphedema. Ann Plast Surg.
2011;67(6):589–593.
61. Saaristo AM, Niemi TS, Viitanen TP, et al. Microvascular breast
reconstruction and lymph node transfer for postmastectomy
lymphedema patients. Ann Surg. 2012;255(3):468–473. Saaristo
combined vascularized lymph node transfer with autologous breast
reconstruction and also reported favorable outcomes, with one-third of
patients no longer needing compression therapy and evidence of improved
lymphatic flow on lymphoscintigraphy in five of six cases. The lateral,
superficial groin lymph nodes are harvested for transfer leaving behind the
deeper lymph nodes that drain the leg.
62. Ngyuen A, Chang EI, Suami H, Chang DW. An algorithmic
approach to simultaneous vascularized lymph node transfer with
microvascular breast reconstruction. Ann Surg Oncol.
2015;22(9):2919–2924.
63. Raju A, Chang DW. Vascularized lymph node transfer for treatment
of lymphedema a comprehensive literature review. Ann Surg.
2015;261:1013–1023.
64. Althubaiti GA, Crosby MA, Chang DW. Vascularized
supraclavicular lymph node transfer for lower extremity
lymphedema treatment. Plast Reconstr Surg. 2013;131(1):
133e–135e.
65. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node
transfer using the wrist as a recipient site for management of
postmastectomy upper extremity lymphedema. Plast Reconstr Surg.
2009;123(4):1265–1275.
66. Cheng MH, Huang JJ, Nguyen DH, et al. A novel approach to the
treatment of lower extremity lymphedema by transferring a
vascularized submental lymph node flap to the ankle. Gynecol
Oncol. 2012;126(1):93–98.

SECTION I • Lower Extremity Surgery
4 
Lower extremity sarcoma reconstruction
Goetz A. Giessler and Michael Sauerbier
SYNOPSIS
■ Any lesion in the lower extremity with a clinical history of pain,
continuous growth, size over 5 cm, or deep subfascial localization is
suspicious of a sarcomatous malignancy and should be surgically
biopsied according to established surgical rules.
■ Still the single statistically proven modality of curing sarcomas and
prolonging postsurgical lifespan is surgical excision with wide margins
resulting in a postoperative R0-status. To date, no other neoadjuvant or
postoperative treatment modality can replace this approach. If wide
margins cannot be achieved, adjuvant therapy is indicated for extremity
preservation.
■ Plastic surgical lower extremity sarcoma reconstruction is – especially
in bone sarcoma reconstruction – the classical field of an
interdisciplinary, multimodal approach, and is most commonly together
with tumor- and orthopedic surgeons, oncologic radiotherapists, and
oncologists.
■ Modern oncoplastic reconstructive surgery can provide adequate
reconstructive options for almost any defect size and composition, and
so radical tumor excision can be combined with over 95% extremity
preservation today.
■ The plastic reconstructions in sarcoma related limb-sparing surgery
(LSS) are often demanding and complex and consist of the full spectrum
of plastic surgical options. They should be performed in specialized
centers and specifically adapted to the patient and case profile.
Access the Historical Perspective section online at

Introduction
Soft-tissue and bone sarcomas
Soft-tissue tumors are a highly heterogenous group of about
100 different tumor entities, which are still classified
histogenetically according to the main adult tissue component
they resemble most. The malignant subgroup among them is
called sarcomas, which not only have the potential to grow
locally invasive or even demonstrate destructive growth but
also have a variable risk of recurrence and metastatic poten-
tial. As the term “sarcoma” (derived from the Greek word
σαρξ “sarx” = “meat”) itself does not necessarily imply fast,
expansive growth, or metastasis, a further subclassification
system into more aggressive sarcomas (high-grade, poorly
differentiated) or less aggressive (low-grade, well differenti-
ated) types does exist. Some lesions like the atypical fibroxan-
thoma are called “pseudosarcomas”, as they demonstrate
a benign clinical course but are histologically malignant.
However, usually well-differentiated tumors show low-grade
characteristics and vice versa.
Primary bone sarcomas are even less frequent than soft-
tissue sarcomas, and most malignant osseous lesions are
metastatic, especially in advanced age. Despite having a low
incidence, bone sarcomas have a high significance for both
patient and surgeon due to their impact on extremity function
and overall mobility. Limb preserving surgery after wide
tumor resections frequently poses a real challenge for the
reconstructive surgeon.
Sarcomas can occur in every part of the body, as they
derive from mesodermic tissue like muscle, nerve, bone
cartilage, blood vessels, or fat. The therapeutic mainstay for
soft-tissue sarcomas is based on surgical excision, whereas
radiotherapy and less so chemotherapy are used as adjunct
adjuvant therapeutic modalities. In primary osseous sarcomas
neoadjuvant chemotherapy plays a more important role. The
complexity of the surgical resection and the subsequent plastic
surgical reconstruction differs considerably depending on the
localization.
Like any oncologic discipline, sarcoma treatment is a typical
field of modern interdisciplinary and multimodal therapy.
Lower extremity sarcoma reconstruction is – especially in
bone sarcoma reconstruction – also a fascinating field for
an effective interaction between the surgical disciplines of

94
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
Basic science/disease process
Epidemiology soft-tissue sarcomas
Soft-tissue sarcomas are a rare disease entity with an incidence
of 1 : 100 000 in adults and 10–15% in children. This accounts
for an incidence of about 10 600 new cases in 2009 in the USA
representing 1–2% of all malignancies ().
There is no overall significant gender predisposition, and the
overall median age at presentation is between 50 and 60 years
of age.
With about 45% of all sarcomas occurring in the lower
extremity, 15% in the upper extremity, 10% in the head and
neck region, 15% in the retroperitoneal space, and the remain-
ing 15% in the abdomen and the chest wall,6 the musculoskel-
etal system of the extremities and the abdominal and thoracic
walls are the most common predilection sites. Extremity sar-
comas are most common in the thigh (50–60%).
While most cases of soft-tissue sarcomas are sporadic, there
are some genetic and non-genetic risk factors summarized
in Table 4.1. Up to 60% of all soft-tissue sarcomas contain a
somatic mutation of p53.7 A detailed description of the various
risk factors is beyond the scope of this chapter, but there are
several strong associations to be mentioned: a history of radia-
tion exposure accounts for up to 5.5% of all sarcomas. The risk
is dose dependent, and the latency period between radiation
and clinical tumor manifestation is around 5 years. Over
80% of radiation-associated sarcomas are high-grade types.8
Neurofibromatosis type NF-1 is strongly associated with the
cumulative lifetime risk of up to 13% for the occurrence of
malignant peripheral nerve sheath tumors (MPNST).
orthopedic, oncologic, pediatric, and podiatric surgeons and
plastic reconstructive (micro-)surgeons.
Modern plastic reconstructive surgery can provide adequate
reconstructive options for almost any defect size and compo-
sition, so considerations about defect size should not play a
role during tumor excision. Today, over 95% of the extremities
can be preserved after radical tumor excision. The plastic
reconstructive procedures are often demanding and complex
and frequently encompass the full spectrum of plastic surgical
options. These procedures may be best performed in special-
ized centers where regimens individually adapted to patient
and case profiles may be optimized.
Sarcomas in the lower extremity
Sarcomas in the lower extremity are more common than in
the upper limb (74% vs. 26%) and represent the most common
location of sarcomas in the body overall (45%).1 Currently,
they are safely treatable by extremity preservation in most
cases, if properly performed according to the rules described
in this chapter and in the pertinent current literature. In this
context, several studies have now demonstrated that LSS is
oncologically not inferior to amputation in the treatment of
lower extremity sarcoma.9 While amputation was still the
keystone of previous surgical therapy several decades ago, it
usually represents only an important last line therapeutic
modality today. The common misconceptions that amputa-
tions have a better outcome both in tumor safety and quality
of life have both definitely been proven wrong.2–4
Sarcomas are rare, and a “soft tissue swelling” is often
misinterpreted by both patient and physician because of this
fact. This can considerably delay proper diagnosis. Still, tumor
manifestations in the extremities are often detected a bit
earlier than in the trunk, as the extremities are constantly
under personal “visual” control in daily life. This might be
even truer for tumors on the upper extremity than on the
lower.
Due to the highly functional anatomy of our extremities
with vessels, nerves, tendons, bones, and muscles in the close
vicinity, even smaller tumors can represent a challenge to both
the resecting tumor surgeon as well as the reconstructive
plastic surgeon. Preservation of the lower extremity in sarcoma
reconstruction differs from alike manifestations in the upper
extremity5 in several key points that have to be considered
carefully:
■ Stability and weight-bearing capability are usually
regarded higher than functional mobility or range of
motion in the lower extremity.
■ Postoperative appearance is usually less important. In
most urban cultures the reconstructed legs with their
scars and possible voluminous flaps can easily be hidden
in clothing and have a less important role in social
interaction than the upper extremity (i.e., handshaking).
■ Weight-bearing demands are higher and atherosclerotic
vessel damage and orthostatic venous pressure are more
profound in the lower extremity. Both may play a major
role in free tissue transfer.
■ Nerve regeneration is less successful in the lower
extremity at any age.
■ Wound healing is slower, and the risk for an infectious
complication is higher.
Table 4.1  Predisposing factors for soft-tissue sarcomas
Genetic
Neurofibromatosis NF-1 (von
Recklinghausen disease)
Retinoblastoma
Gardner’s syndrome
Werner’s syndrome
Bloom’s syndrome
Fumarate hydratase leiomyosarcoma
syndrome
Diamond–Blackfan anemia
Mechanical
Li–Fraumeni syndrome
Postparturition
Chemical
Chronic irritation
Polyvinylchloride (PVC)
Hemochromatosis
Dioxin (TCDD) “Agent Orange”
Radiation
Arsenic
Traumatic–accidental
Lymphedema
Post-therapeutic
Parasitic (filariasis)
Iatrogenic
Stewart–Treves syndrome
Infectious (viral)
Congenital
Kaposi sarcoma (HHV-8)
HHV-8, human herpes virus-8; TCDD, 2,3,7,8-tetrachlorodibenzodioxin.

95
Diagnosis/patient presentation/imaging
population. Chondrosarcomas are slow growing and rela-
tively resistant to adjuvant therapy.
Ewing’s sarcoma is classically located in the femur diaphy-
sis in teenagers, and only 20% occur in middle-aged adults. If
found extradiaphyseal, it is very common in the pelvis. It is
the most common primary bone malignancy of the fibula. The
Ewing’s sarcoma is very radiation sensitive.
Tumor growth and metastasizing
Sarcomas in the extremity may spread locally by continuous
expanding growth irrespective of anatomic borders. In many
cases it mistakingly seems that the tumor has developed a
bordering capsule to surrounding “healthy tissue”. However,
this capsule is part of the tumor, and soft-tissue satellite-like
or intraosseous skip-lesion tumor manifestations are beyond
this capsule. This fact represents the main justification for a
modern wide-resection concept in sarcoma surgery.
Hematogenic spread is most common in soft-tissue and
bone sarcomas. For lower extremity tumors, the primary site
for metastasis is the lung. Lymphatic metastases are present
in less than 5% of all soft-tissue sarcomas (rhabdomyosar-
coma, angiosarcoma, and epitheloid-like sarcoma).13,14
Diagnosis/patient presentation/imaging
A detailed history and physical examination is the first initial
and very important step to professional tumor surgery. In
sarcomatous lesions, the patient often relates the tumor caus-
ally to an – often minor – traumatic event, bringing the lesion
into clinical attention to the patient. Acute trauma, however,
is not a proven predisposing factor for sarcoma development.
Because of this, there is often a considerable time lag between
this initial recognition and the first presentation of the lesion
to a medical professional. Furthermore, the rationale of the
lesion is often erratically misinterpreted and then causes a
variety of inadequate treatments by both lays and physicians,
further delaying proper diagnosis. The average duration of
any symptoms before seeing a physician is 6 months in all
soft-tissue sarcomas, but possibly shorter in extremity mani-
festation.3 So in adults, lesions that (1) have not disappeared
after 4 weeks, (2) are located subfascially or in the popliteal
or groin flexion creases, (3) continue to grow or are symptom-
atic (i.e., pain and paresthesias), or (4) are already larger than
5 cm on detection should generally be biopsied as they are
highly suspicious for malignancy.
It is not unusual that sarcomas are found by physicians in
the context of a workup for a completely different medical
problem (i.e., chronic venous insufficiency in the leg). Coinci-
dental findings like articular pain and joint effusions are
common especially with osseous sarcomas, whereas clinically
manifest neurovascular symptoms are relatively rare at initial
presentation. Two-thirds of sarcoma patients present with a
painless mass during their first clinical examination, and only
one-third have current pain or have had a history of pain in
the affected region.
The thorough physical examination is not only focused on
the affected extremity but includes the complete body. The
pertaining lymph node stations should be examined as well,
even though lymphatic spread is uncommon in the majority
of all sarcoma types. The general health status should be
The sarcoma subtype is determined by light- and electron
microscopy, immunohistochemistry, and cytogenetic analysis.
If it results in a tumor that cannot be designated accordingly,
a descriptive evaluation is given for an “unclassified sarcoma”.
Obtaining reference pathologies for soft- and bone-tissue
sarcomas should be standard, as the rate of diagnostic agree-
ment among specialists is below 75%.9,10 The most common
histopathologic subtype distribution in extremities in the
largest series in the literature is shown in Fig. 4.1.
Bone sarcomas
About 2600 new primary bone sarcomas occur each year
in the USA (). The overall median age
at diagnosis is 39 years. Many predisposing factors for
bone sarcomas are similar to those for soft-tissue sarcomas
(like retinoblastoma, Li–Fraumeni syndrome, radiation, and
others) (Table 4.1). Paget’s disease, bone infarction, and
fibrous dysplasia may also represent risk factors for bone
sarcomas.
The most common type is the osteogenic sarcoma, which
has a predilection for the metaphyses around the knee in
about 50% of cases. It is the third most common cancer in the
young () with a second peak around age 60. The
male to female ratio is almost 2 : 1 in large studies, and for
this specific tumor the median age at diagnosis is 17 years.
Only 6.4% present initially with pathologic fractures, whereas
the majority are detected in the workup of a painful mass
or swollen extremity.11,12 It commonly arises in the medulla,
but as a juxtacortical osteogenic sarcoma it arises from the
external surface – most commonly the posterior aspect of
the femur.
The spindle cell mesenchymal sarcoma group contains
chondrosarcomas, intraosseous malignant fibrous histiocyto-
mas (MFHs), and fibrosarcomas. The tumors of this group
only have an incidence of about two-thirds of the incidence
of osteogenic sarcomas and primarily occur in an older
Fig. 4.1  Distribution of histopathologic types in extremity soft-tissue sarcomas.
MFH, malignant fibrous histiocytoma. (From: Weitz J, Antonescu CR, Brennan MF.
Localized extremity soft-tissue sarcoma: improved knowledge with unchanged
survival over time. J Clin Oncol. 2003;21:2719–2725.)
9%
12%
Leiomyosarcoma
Fibrosarcoma
Synovial sarcoma
Liposarcoma
MFH
14%
27%
38%

95.e1
Historical perspectives
Historical perspectives
The term sarcoma was first used by Abernethy in1804 and was
based on the gross characteristic of the tumors. Codman
founded the first Bone and Soft Tissue Sarcoma Registry in
1909, containing information on the diagnosis and treatment
of bone. In 1829 Jean Cruveilhier published a two-volume
work on pathologic anatomy, containing a substantial amount
of information about sarcomas as they are understood today.
Since then, the classical treatment of a sarcoma in the lower
extremity was amputation, accounting for relatively low
recurrence rates, but with a severe impact on the integrity of
the patient. In 1879 Samuel W. Gross published his experi-
ences with 165 sarcoma cases of the long bones, in which he
advocated early amputation despite the prevailing operative
mortality rate of 30%. Based on his study, limb-salvaging
resection inevitably led to local recurrence, metastasis, and
death. Following this study, an even more aggressive approach
to bone tumors was popularized, but survival rates did not
improve significantly. This stimulated the first adjuvant radia-
tion treatment of bone tumors.
However, the mortality rate of radiated patients equaled
the mortality rate of patients who underwent amputation. The
first neoadjuvant protocol was developed in 1940 by Cade and
Ferguson, who combined preoperative radiation followed by
amputation 6 months later in metastasis-free patients. The
aim of the protocol was to avoid unnecessary amputation.
The transition between amputation surgery and limb-
sparing surgery was less of a plastic surgical issue than an
oncologic–orthopedic development: reconstructive proce-
dures after sarcoma resection were very uncommon until the
number of limb-preserving resections increased.
Episodic anecdotes reporting on limb salvage appear as
early as 1895, when Mikulicz described two resection arthrod-
eses of the knee for distal femoral lesions in Europe. Sauer-
bruch in Germany described his “Umkippplastik” in 1922 as
the precursor of today’s rotationplasty. A first systematic
approach to limb salvage was suggested in 1940 by Phemister
in his article “Conservative Bone Surgery in the Treatment of
Bone Tumors”.15
After WWII more surgeons began to explore limb-salvaging
resection instead of amputation. It became clear that obtaining
adequate surgical margins is a key issue for cases with resect-
able tumors according to their pathologic characteristics.
Their work established the principles of today’s limb-salvaging
surgery despite the limited reconstructive modalities at that
time.
The surgical treatment of malignant bone tumors was revo-
lutionized in the early 1970s by the development of chemo-
therapy, improved diagnostic radiology by more accurate
CT and MRI scanners, advances in reconstructive surgery,
improvements in orthopedic oncologic surgery, and, eventu-
ally, the establishment of multidisciplinary tumor centers.
These advances are mainly responsible for the reduction in
local recurrences after limb-salvaging procedures by allowing
a better patient selection and a more accurate preoperative
planning.
During these developments, many sophisticated plastic
surgical techniques were developed in a fascinating history
that is covered in a different volume of this textbook. Most of
the techniques were focused on soft-tissue reconstruction, but
later composite tissue transplants and grafts were improved
as well. Many new techniques were derived from trauma
surgery, the treatment of congenital disorders, or tumor
surgery elsewhere in the body and did not specifically relate
to the development of sarcoma surgery, but were quickly
adapted to limb-preserving tumor reconstruction. Sophisti-
cated pedicled reconstructive methods like cross leg flaps,
tubed pedicled flaps, or fibula pro tibia transfers were stan-
dard procedures in early LSS until microvascular surgery was
integrated into the plastic surgical armamentarium.
Modern reconstructive approaches integrate the latest
advances in orthopedic surgery, such as modular and custom-
made tumor prostheses for long bone and joint replacement,
with the full spectrum of the plastic surgical reconstructive
ladder including chimeric multi-tissue-type free flaps in limb-
sparing lower extremity sarcoma reconstruction.

96
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
Patient profile/general considerations/
treatment planning
Patient profile
The goals of surgery in sarcoma reconstruction in the lower
extremity depend on the individual case profile, which is
composed of personal factors and the available reconstructive
options. The most important personal factors that need to be
taken into consideration are age, size, and weight; concomi-
tant chronic diseases relevant to general health and operabil-
ity; medications; social status; functional and aesthetic
conceptions; previous operations; and tissue quality of the
affected extremity.
The pertinent reconstructive options that need to be dis-
cussed with the patient are the relevant operative methods
according to the applicable steps of the reconstructive ladder,
counterweighing their advantages and disadvantages for the
actual tumor stage, location, oncologic safety, and potential
adjuvant procedures (i.e., irradiation).
General considerations
Above all, the prime goal should be an R0-resection with
tumor-free and adequately wide margins, which provides the
best chance of complete surgical cure of the disease. This
might create a considerable surgical defect and can imply
major surgical reconstructive procedures for the patient. The
extent of adequate wide tissue resection is almost never real-
ized by the patient presenting with a palpable mass and has
to be explained to him or her in detail.
assessed and optimized by all relevant medical specialties.
This is especially important in multimorbid patients with
concomitant acute and chronic comorbidities in the context of
the planned operative procedures. Terminal illnesses and
comorbidities have to be taken into consideration for the
extent of both resection and reconstructive surgery.
Clinical assessment and staging of the patient must be
completed by adequate imaging diagnostics for evaluating
local and generalized tumor manifestations. Any imaging of
the tumor region must be performed before any surgical
biopsy as the latter may confound the picture to a consider-
able extent.
Gadolinium contrast-enhanced magnetic resonance imag-
ing (MRI) is currently the diagnostic mainstay to define exact
tumor location, its relation to neighboring neurovascular
structures and muscular compartments, to determine its
homogeneity, integrity, and vascularization, and its presumed
main tissue component. MRI is specifically useful for detect-
ing skip lesions. It allows 3D planning of the resection and
helps to assess the necessary reconstruction procedures
preoperatively.
Modern spiral computerized tomography (CT) scans are
indispensable for clarifying the detailed anatomy of osseous
sarcomas, determining the extent to which skeletal structures
are affected by neighboring soft-tissue tumors, and aiding in
operative planning of these sarcomatous entities. Thoracic
and abdominal CT-scans are the diagnostics of choice for
staging of high-grade sarcomas of the extremities and detect
intrapulmonary and abdominal metastases. In recurrent
disease, positron emission tomography (PET) CT can augment
the information about suspicious lesions in selected cases,
though not accepted as a standard instrument for the preop-
erative workup (see Chapter 7).16–18
CT-angiography with 3D-reconstructions is a valuable
tool in determining the overall vascular status of the affected
leg, the underlying generalized vessel disease, and the vas-
cularity of the tumor, and showing vascular displacements,
collateral perfusion systems, vessel invasion, and tumor-
related occlusion. They also provide valuable information
about the feasibility of microvascular anastomoses and the
presence of suitable recipient vessels, especially in elderly
patients.
Plain X-ray films demonstrate specific periosteal or cortical
signs, osteolysis, and paraosseous calcifications in diaphyseal
and metaphyseal bony lesions. Even today, a plain radiograph
remains the diagnostic method of choice for primary bone
sarcomas (Fig. 4.2). A plain chest radiograph is still considered
the standard for clinical staging in low-grade extremity
lesions.
Ultrasound with or without contrast media is a cheap, fast,
and painless adjunctive diagnostic measure that may be
especially helpful in highly vascularized tumors. Ultrasound
was often the diagnostic device of coincidental tumor findings
but is also used for getting an initial overall picture of the
lesion.
A 99m-Tc-pyrophosphate bone scan is essential to bone
tumor staging and screening for multicentric disease or
metastases.
A special laboratory workup for soft-tissue sarcomas does
not exist, whereas elevated alkaline phosphatase and lactate
dehydrogenase over 400 U/L are independent predictors of
an unfavorable outcome in bone sarcomas.19
Fig. 4.2  Typical radiologic features of malignant and benign primary osseous
tumors.
Onion ring sign
Spiculae
Codman’s triangle
(singular
periosteal lamella)
Solid periosteal
reaction
Extended
osteolysis
Piecemeal
lesions
Tumor
permeation

97
Patient profile/general considerations/treatment planning
If surgical cure is not possible, resection of as much tumor
mass as possible (tumor debulking) is paramount (R1/R2) and
usually followed by adjuvant radio- and (less frequently)
chemotherapy according to the recommendations of a multi-
disciplinary tumor board. At this point, the reconstructive
goal should aim for a functional lower extremity capable of
full weight-bearing that appears as aesthetically pleasing as
possible in the given case and circumstances. The surgical
therapy should create a status for the patient to be integrated
in social life, allowing him or her to wear normal clothing and
having a closed skin envelope. In selected cases, creating a
stable open chronic wound is the only remaining palliative
option; however, it should be free of copious discharge and
secretions and avoid any olfactory nuisances. For example, a
stable open wound producing minimal drainage that can be
treated by daily dressing changes at home may offer a higher
quality of life than performing another resection and recon-
structive effort that may force the patient to stay in the clinic
during his or her last days.
Treatment planning
Each case should be discussed in the multidisciplinary tumor
board with all relevant medical disciplines involved in the
setup of a treatment plan (tumor surgeon, medical oncolo-
gist, orthopedic surgeon, plastic surgeon, internal medicine,
psychologist, radiologist, oncologic radiotherapy specialist,
prosthetic technician, etc.). For optimal planning and strat-
egy development, all diagnostic procedures, the radiologic
imaging, and the definitive histology should already be
present (see below).
A thorough and complete discussion of the tumor-board
treatment recommendations are explained to and discussed
with the patient including all operative options (including
amputation) and neoadjuvant or adjuvant chemo- or radio-
therapy. It is important for many patients to have an outline
of the timeframe for the various surgical or multimodal thera-
peutic options.
Finally, tumor staging is done according to the current
staging systems for soft-tissue sarcomas. The American Joint
Committee on Cancer (AJCC) system is designed for extrem-
ity sarcomas (Table 4.2), including most but not all histologic
subtypes. Dermatofibrosarcoma protuberans (DFSP) and
angiosarcoma, among others, are exempt from staging with
the AJCC. For primary bone sarcomas like the osteogenic
sarcoma, the Musculoskeletal Tumor Society (Table 4.3)
staging system is used.
Surgery
To date, no other treatment modality provides better cure for
sarcomas than adequate surgery. Oncologic safety is para-
mount, but preservation of the leg or foot should be achieved
to preserve patient integrity, which is usually possible.
This avoids the need for prosthesis adaptation and use,
and prosthesis-related problems. Several considerations in
sarcoma-related defect reconstruction need to be mentioned
that differ from sarcoma-related surgery at the upper extrem-
ity. The capability for stable weight-bearing is more important
than joint mobility in the lower extremity, whereas preserva-
tion or restoration of sensitivity is less important on the leg
and foot than on the arm or hand. While sensitivity should be
(Reproduced from Papagelopoulos PJ, Mavrogenis AF, Mastorakos DP, et al.
Current concepts for management of soft-tissue sarcomas of the extremities.
J Surg Orthop Adv. 2008;17:204–215.)
Table 4.2  American Joint Committee on Cancer staging system:
predisposing factors for soft-tissue sarcomas
Classification
and staging
Characteristic
Primary tumor (T)
T1
Tumor 5 cm or less in greatest dimension
T1a
Superficial tumor (in relation to investing fascia)
T1b
Deep tumor (visceral and retroperitoneal
sarcomas are defined as deep tumors)
T2
Tumor larger than 5 cm in greatest dimension
T2a
Superficial tumor
T2b
Deep tumor
Regional lymph nodes (N)
N0
No evidence of nodal metastasis
N1
Nodal metastasis present
Distant metastasis (M)
M0
No distant metastasis
M1
Distant metastasis present
Grade (G)
G1
Low-grade
G2 and G3
High-grade
Staging
Stage I
Low-grade tumors, no evidence of regional
nodes or distant metastases (T1a, T1b, T2a,
T2b)
Stage II
High-grade small tumors (T1a and b) and
superficial large tumors (T2a), no evidence
of regional nodes or distal metastases
Stage III
High-grade deep tumors larger than 5 cm
(T2b), no evidence of regional nodes or
distant metastases
Stage IV
Any tumor with regional nodes or distant
metastases
Table 4.3  Musculoskeletal Tumor Society staging system
Stage
Characteristic
IA
Low-grade, intracompartmental
IB
Low-grade, extracompartmental
IIA
High-grade, intracompartmental
IIB
High-grade, extracompartmental
IIIA
Low- or high-grade, intracompartental with metastases
IIIB
Low- or high-grade, extracompartental with metastases
(Reproduced from Papagelopoulos PJ, Mavrogenis AF, Mastorakos DP, et al.
Current concepts for management of soft-tissue sarcomas of the extremities.
J Surg Orthop Adv. 2008;17:204–215.)

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SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
aspiration with a 23-gauge needle usually harvests only a
very small number of cells, the volume of tissue gained from
a core-needle biopsy is a bit higher. Still, both methods have
the disadvantage of not representing the tumor tissue compo-
nents correctly, especially in larger tumors, which makes it
very difficult for the histopathologist to find the exact diag-
nosis, perform the necessary number of different studies, and
determine the correct grading. However, if combined with
CT-scan or ultrasound guided needle placement, core biopsies
may achieve a correct diagnosis in up to 90% of cases under
optimal circumstances. Fine-needle aspirations only reach
56–72%.20–22 While single core-biopsies may harvest too little
tissue for an extensive pathologic workup with several stain-
ings and immunohistochemical diagnostics, they provide the
advantage of gathering tissue from different parts of the
tumor to create a comprehensive picture.22
Both methods are atraumatic and only very rarely cause
dangerous tumor-cell dissipating hematomas. In several
institutions, core biopsies are reserved for surgically unre-
sectable tumors (i.e., retroperitoneal lesions) to determine
tissue type and guide an eventual neoadjuvant therapy,3
while others use it as a prime diagnostic tissue sampling
method.22
In summary, fine needle biopsies do not have a place in
sarcoma diagnosis in the lower extremities, and both core
biopsy and open surgical biopsy are very operator dependent:
if poorly performed, the risk of getting an inadequate diag-
nostic sample or tumor seeding is high, respectively.23,24 Bone
forming lesions are very difficult to adequately sample percu-
taneously, and open biopsies are preferable.25
Excisional biopsy
Excisional biopsies aim for the removal in toto of all tumor
tissue with primary closure of the surrounding tissue and are
therefore reserved for lesions less than 3–5 cm in diameter
and with epifascial location. As the definitive diagnosis is not
known beforehand, no tissue margin of defined thickness is
left with this procedure.
Any surgical biopsy on the lower extremity should be
performed with a pressurized tourniquet (no exsanguination!)
if tumor location permits. The bloodless field not only aids in
exact and atraumatic safe dissection but also inhibits possible
tumor cell contamination during surgery.
Before incising the skin, it is absolutely necessary that the
surgeon already imagines any secondary, definitive tumor
resections and has possible muscle and tendon transfers and
local flap options in mind. The biopsy incision should interfere
as little as possible with these factors. Usually, a longitudinal
incision as short as possible for an adequate exposure directly
over the tumor is made, providing the shortest reasonable
access route to the neoplasm.
The tumor should be excised in a no-touch/no-see tech-
nique including any pseudocapsule (if present) without
opening it. Any “shelling-out” of the tumor should not be
performed as in sarcomas this capsule is part of the tumor and
its remaining walls do contain tumor cells.
After the excision, it may be useful to mark the resection
bed with titanium or vitallium microclips to make later exci-
sion easier, if malignancy was affirmed. Localization sutures
are fixed to the tumor, and both instruments and gloves are
changed.
preserved as much as possible, in selective cases, asensitive
“stilt-legs” are considered superior to amputations, especially
in elderly patients that would have problems adapting to
prosthesis handling. Not being able to preserve the main
nerves and thereby sensitivity is not an indication for amputa-
tion by itself!
Radiotherapy
Radiotherapy is the primary adjunctive treatment method in
sarcoma management today. Neoadjuvant radiation in large
sarcomas uses external beam irradiation that helps in tumor
shrinkage and thickening of the tumor capsule, which facili-
tates adequate resection and the achievement of negative
margins during wide resection and reduces potential surgical
tumor seeding. The disadvantages of preoperative irradiation
are a higher rate of wound healing complications compared
to postoperative radiotherapy and the creation of necrotic
tumor material for the pathologist.2
Intraoperative radiation comprises a single dose electron
radiation and has indications for use in the lower extremity
for locations around the groin and foot. It is especially effec-
tive when the tumor dose is increased relative to the normal
tissue dose. However, its availability is limited even in modern
tumor centers.
Postoperative irradiation is done with brachytherapy and
electron beam therapy both used in solitary and combination
regimens. Brachytherapy is especially useful after resection of
local recurrences in a previously irradiated field.
Chemotherapy
To date, any adjuvant or neoadjuvant chemotherapy for sar-
comas should only be conducted in clinical studies (EORTC,
COSS, EURO-Ewing, etc.). The various protocols are beyond
the scope of this chapter and are changing rapidly. The reader
is therefore advised to consult the pertinent most recent litera-
ture on that matter.
Isolated extremity perfusion or hyperthermia is currently
indicated for patients that would otherwise require primary
amputation. The precise selection criteria have not been
clearly defined yet, and valid comparisons to other approaches
are lacking.2
Treatment/surgical resection
techniques
Histologic confirmation, grading, and subtyping of the pre-
sumed malignant sarcomatous tumor on the lower extremity
must be achieved before the overall treatment strategy is
planned in the tumor board and definitive, usually more
extensive, surgery is initiated. However, not all known biopsy
techniques are useful for a correct and safe diagnosis of a
sarcoma.
Biopsy techniques
Fine-needle or core-needle aspirations
These techniques gain only a very small amount of tissue
even in the hands of an experienced clinician. While tissue

99
Treatment/surgical resection techniques
immobilized – especially in procedures close to joints. Tem-
porary splinting or an external fixator for a few days serves
the purpose here.
When mounting an external fixator to the affected lower
extremity at the time of biopsy, care must be taken not to
interfere with the later resection margins for definitive tumor
resection. Preoperative findings of intraosseous skip lesions
in bone sarcomas must be taken into consideration in this
context. A fixator pin must never be set into an area for later
resection, or the pin tract has to be included in the resection
specimen.
Both incisional and excisional biopsies are not intended to
adequately remove the tumor according to oncologic rules.
Therefore, temporary vacuum-assisted closure techniques
should be avoided and are rarely required anyway. Their
angiogenetic potential and the risk of dissipation of tumor-cell
containing wound secretions into the rest of the wound may
negatively affect local oncologic safety. Larger studies are
missing, however.
Re-operative biopsies and surgical revisions
Tumor centers frequently have to perform a surgical revision
to confirm the diagnosis of sarcoma or to accomplish
the correct surgical–oncological treatment. After previous
attempts of inadequate biopsy or even after surgery that was
intended to be definitive and curative, a re-operation is con-
sidered mandatory if at least one of the following situations
is present:
■ Only inadequate tissue material for definitive histology
was gained at the first operation.
■ Previous resections have not been performed according
to current oncologic guidelines (see Case 4.2). Some
indicators for a re-operation are incisions placed
horizontally to the axis of the extremity and opening up
several muscle compartments, intact nerve function after
“resection of a malignant peripheral nerve sheath tumor”,
or normal leg motor function after “radical excision of
extensor or flexor muscles”.
■ A clinically unsuspicious and presumably benign tumor
was resected with the techniques of benign tumor
surgery, but the postoperative histopathologic workup
showed an unexpected malignancy.
■ A tumor was resected during a non-oncologic surgery
and detected in the postoperative workup (“unplanned
excision”).
■ The tumor surface was visible intraoperatively.
■ Previous operating room (OR) reports describe an “easy
shelling-out from a capsule”, but clinical and/or
histologic and/or radiographic workup confirms a highly
suspicious lesion or malignancy. A sarcoma resection out
of its pseudocapsule results in local recurrences in up to
90% of patients.6
■ The patient presents with early local tumor recurrence,
despite a “radical resection” being stated in the previous
OR report.
■ Previous OR reports state a “compartment resection” in
the axilla or around the elbow, popliteal fossa, or groin
(which is anatomically not possible).
■ OR and pathologic reports differ considerably in amount
and integrity of the resected tumor.
Meticulous hemostasis and the placement of a closed
suction drainage within the wound to prevent possible
tumor seeding through a hematoma are paramount before a
multilayered skin closure is done. The skin should be closed
with single interrupted stitches or intracutaneous sutures.
Mattress sutures or separate drainage perforations leave stitch
marks too far away from the incision and, as they all have to
be excised in case of malignancy, this would enlarge the
amount of tissue to be resected. A sterile circular compressive
dressing is placed, and the affected extremity is immobilized
– especially in procedures close to joints. Temporary splinting
for a few days assists well here.3
Incisional biopsy
The surgical resection of a representative part of the sarcoma
is the gold standard in diagnosis of extremity tumors for any
lesions that are larger than 3–5 cm and of subfascial location.
This technique should only be performed by an experienced
surgeon, as the gathering of respective tissue specimens and
the handling of the tissue is crucial to the success of the pro-
cedure. The advantages of getting adequate tissue for a full
range of diagnostics greatly outweigh the disadvantages by
opening the tumor and introducing the potential for tumor
cell seeding in the path of the access route.
Again, the procedure should be performed with a tourni-
quet, as detailed dissection is possible and intraoperative
contamination of surrounding tissue areas during resection of
the histologic specimen with potentially tumor-cell contain-
ing blood is minimized.
The guidelines for the skin incision are practically the same
as for the excisional biopsies with regard to keeping any
further operative options in mind. An incision parallel to the
axis of the extremity is made. It should be as short as possible
for an adequate exposure directly over the tumor providing
the shortest reasonable access route to the neoplasm. The
incision must not unnecessarily interfere with later procedures
needed to cover the defect.
A properly conducted incision biopsy should harvest a
relevantly large, at least 2 × 1 × 1 cm, tissue block from all areas
of the tumor including the capsule. It is a common misconcep-
tion to want to gain tissue only from the central portion, as
this area often contains considerable amounts of necrotic
tissue that are not adequate for pathology and makes defini-
tive histologic classification impossible. The tissue block
removed should be manipulated as little as possible and
should not come into contact with the wound edges of the
surgical access route. Any instrument used to hold or manipu-
late the biopsy specimen must not be used for wound closure
or retraction, etc. After removal of the tumor block, localiza-
tion sutures are tied and both instruments and gloves are
changed.
Meticulous hemostasis and the placement of a closed
suction drainage within the wound to prevent possible
tumor seeding through a hematoma are paramount before a
multilayered skin closure is done. The skin should be closed
with single interrupted stitches or intracutaneous sutures.
Mattress sutures or separate drainage perforations leave
stitch marks too far away from the incision and, as they all
have to be excised in case of malignancy, this would enlarge
the amount of tissue to be resected. A sterile circular com-
pressive dressing is placed, and the affected extremity is

100
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
technique leaving a cuff of macroscopically unaffected tissue
of 2–5 cm around it. Still there are no conclusive studies about
the exact margins in sarcoma surgery, but many centers cur-
rently recommend a margin of 2 cm from the deep surface of
the tumor and 4–5 cm laterally.2,3,20,26 Any palpable pseudo-
capsule of the tumor belongs to the tumor itself and should
be resected but not opened or seen at all, otherwise the pro-
cedure is regarded as a R1-resection. The tumor should not be
retracted or manipulated with sharp or pointed-tipped instru-
ments and should be resected in continuity with the skin
island containing the previous incision.
The aforementioned margins are often difficult to maintain
in the periphery of the lower extremity. Under these circum-
stances, ray amputations may suffice to achieve comparable
local recurrence rates (<10%) if combined with local deperiosta-
tion and tenosynovectomy.3
Vascular involvement
Relevant deep vascular structures that are not directly infil-
trated or encased in the tumor can usually be treated by
longitudinal opening of the vascular adventitia opposite the
tumor and subsequent microsurgical stripping of the adven-
titia under loupe magnification and en bloc with the tumor.
Accompanying veins are usually ligated and included in this
specimen if venous drainage of the extremity is still guaran-
teed in a different compartment. Preoperative MRI helps in
this decision, otherwise the affected vessels have to be resected
en bloc and replaced by a venous patch (less common), a vein
graft, or, less commonly, an artificial vessel graft material (i.e.,
Gore-Tex). Any arterial side branches that do not lead into the
tumor should be evaluated as possible recipient vessels for
microvascular tissue reconstruction and be preserved. Preser-
vation of septal branches or muscular vessels that are outside
the tumor resection area may lifeguard local or regional
muscle and skin flaps that can not only aid in postoperative
dead-space elimination and wound closure but also in simple
primary wound healing. Extraneous vessel ligation should
therefore be avoided.
If the superficial venous systems (great and lesser saphe-
nous veins) are not included in the resected sarcoma specimen,
they should be preserved together with their subcutaneous
branches if possible. This prevents venous congestion if the
deep venous systems close to the tumor must be resected as
mentioned above, adding to the radicality and safety. While
there should always be an adequate arterial perfusion of the
lower extremity after tumor removal, only the main arteries
are reconstructed immediately. Interpositional vein grafts for
large vein reconstruction in tumor patients have a higher risk
of thrombotic failure than in traumatic cases and should be
reserved for selected cases only.
Nerve involvement
The same dissection strategy applies to the main nerves in the
lower extremity. Any affected epineural tissue or connective
tissue around the nerve inside the safety margin around the
tumor should be stripped or removed with careful microsur-
gical techniques. If only a few fascicles of an important main
nerve trunk are adherent to the tumor, it is considered accept-
able to resect these and leave the unaffected nerve bundles
intact for some basic motor function and sensitivity. If a major
■ Any remaining tumor is present in any postoperative
imaging (MRI).
In all these situations, at least an R1-situation must be antici-
pated. The secondary resection should follow the exact
principles of the surgical technique for definitive resection
described below. The previous tumor bed should not be
opened or visualized at all. If macroscopically visible remain-
ing tumor is encountered during surgery (R2-situation), the
secondary revisional surgery may at least reduce the situation
into an R1-situation (Table 4.4). Following these revisional
surgeries, radiotherapy is usually indicated for a reduction in
the probability of local tumor recurrence.
Surgical technique for definitive resection
Soft-tissue sarcomas
As soon as the definitive histology is found and the tumor
type, grading, and staging of the disease has been completed
in the multidisciplinary workup, definitive surgery is initi-
ated. If the tumor is deemed to be resectable and no neoadju-
vant therapy was planned, the therapy of choice today is a
wide excision with adequate margins. Before any definitive
surgery is performed, the reconstructive strategy should be
planned as meticulously as possible. It is necessary to fully
inform the patient about the expected extent and length of the
procedure and of possible donor sites of flaps, nerves, vessels,
or skin grafts, etc. Furthermore, the anesthesiologic risk and
invasiveness of monitoring should be explained to the patient
and planned accordingly with the anesthesiologist. Also,
placement of vascular access routes and regional pain catheters
are important in that aspect. A well planned patient position-
ing on the OR table can allow a simultaneous team approach
by oncologic and plastic surgeons and save a considerable
amount of operative time.
Definitive sarcoma resection with a curative approach
should be performed in a bloodless field with a pneumatic
tourniquet or even temporary occlusion of the iliac or femoral
artery by vascular surgery techniques. This reduces not only
the risk for potential hemorrhage-induced contamination of
the field with tumor cells but blood loss in general and is
mandatory for a detailed dissection.
The resection must include all previous skin incisions, all
previous stitch marks, and drain sites with a margin of 4 cm
of healthy skin around them. This margin is also true for any
ulcerated tumor locations. If the previous incision was per-
formed properly, it creates an elliptical defect along the lon-
gitudinal axis of the leg. The advantages of this orientation
are the preservation of the remaining subdermal lymph
vessels and the ease in wound closure.
After adequate epifascial mobilization, the muscle fascia is
opened and the sarcoma is resected with a no-touch/no-see
Table 4.4  World Health Organization classification of tumor
resection margins
R0
Resection with microscopically tumor-free specimen margins
R1
Resection with microscopically tumor-positive specimen
margins
R2
Resection with macroscopically remaining tumor

101
Treatment/surgical resection techniques
detailed care for exact approximation of the wound edges in
order to avoid any wound-healing disturbances that might
hinder fast implementation of radiation therapy. Primary
wound closure is dependent on the size of the tumor and
the location in the leg. In the thigh, primary wound closure
after wide resections is frequently possible, whereas around
the knee and distally from it in the lower leg this is usually
not feasible. The tumor resection bed should be narrowed
by appropriate muscular and fascial sutures to prevent
seroma and hematoma collection in it. Naturally, this usually
applies for tumor locations at the thigh or proximal lower
leg only.
Any wound closure must aim for a stable skin closure with
only minor tension for fast primary wound healing and must
avoid stretching of thinned-out, unsupported adipofascial
skin flaps over empty wound cavities or bony protuberances.
Wound closure must not be a trade-off against the appropriate
radicality in tumor resection, especially in the context of avail-
able modern plastic surgical reconstructive options.
It is often quite useful to immobilize the operated leg with
a splint for postoperative handling, analgesia, and aiding in
hemostasis. A sterile circular compressive dressing is placed
as well. However, in the case of a flap reconstruction, many
surgeons defer from using this option because of the fear of
compression forces onto the flap or the microvascular pedicle.
An interim placement of external fixators is very useful in this
context. They easily permit the bedside elevation of the oper-
ated extremity, especially in cases with free flaps that may not
be dressed with circular bandages in the first postoperative
days. External fixators may help in later daily wound care and
aid in safe and fast flap healing, but may also be mounted in
the proximal and distal metaphyses when a diaphyseal resec-
tion must be performed, or for interim stabilization until a
surgical arthroplasty is healed or an orthopedic joint replace-
ment is performed.
Depending on the patient and case profile, an immediate
reconstruction may not be possible due to a variety of reasons.
Cardiovascular instability, ventilation problems, a large blood
loss, or unexpected surgical findings may render a continua-
tion of the operation too dangerous, especially in patients
with several comorbidities or advanced biologic age. In these
cases, temporary vacuum-assisted wound closure may be
used until final reconstruction. There is no evidence in the
literature that these angiogenesis-promoting subatmospheric
pressure devices have negative effects on oncologic safety
after a wide resection that was intended to remove all neoplastic
tissue including an appropriate safety margin.28,29 This is in
contrast to the situation after incisional or excisional biopsies
where they are not recommended for use (see above).
Lymph node dissection
Less than 5% of all sarcomas spread in a lymphatic way.
Therefore there is no indication for a standardized simultane-
ous dissection of the relevant lymph node areas (i.e., popliteal
fossa/groin) if the region is not clearly involved clinically or
radiographically. A lymph node dissection should always be
performed, however, in sarcomatous tumor entities that are
known for their lymphatic spread like the rhabdomyosar-
coma, angiosarcoma, and epitheloid-like sarcoma subtypes. If
regional lymph node metastases are present, a radical lymph-
adenectomy significantly improves median survival.13,14
nerve is encased completely, it must be resected and should
be reconstructed primarily or secondarily (see Chapter 6).
Osseous involvement
For soft-tissue tumors in the lower extremity that are not
primary osseous sarcomas and growing close to bone, the
appropriate treatment has to be guided by clinical judgment
and preoperative MRI and CT-scan. Real bony arrosion is
relatively rare, and periosteal stripping, decortication, and
partial bone resection are reasonable methods to comply with
safe margins according to the principles of wide resection.
However, these procedures weaken the bone mechanically in
an area where later adjuvant radiotherapy further weakens
the bone in the beam to an extent that may actually cause
spontaneous fractures. Together with a systemically prevalent
osteoporosis, this poses a considerable risk for spontaneous
fractures.3,27 Any resection of weight-bearing bones and joint
segments should be balanced carefully against the complexity
to reconstruct them. Frequently, the preservation of important
skeletal structures permits quality of life to a degree that is
comparable to an acceptable oncologic risk. Nevertheless, the
full range of the plastic reconstructive operative armamen-
tarium including bone flaps should be evaluated in providing
the best outcome for the patient (see Chapter 6).
Primary osseous sarcomas
Primary osseous sarcomas may be diagnosed relatively accu-
rately by plain radiographic imaging alone. The biopsy tech-
niques are the same as in soft-tissue sarcomas, with the
addition of opening up the bone cortex with a round burr hole
under X-ray-assisted localization; gaining the biopsy; obtain-
ing wound swabs for bacteria, fungi, and tuberculosis (dif-
ferential diagnosis); and closing the hole with alloplastic
hemostatic material.25
Wide surgical resection is also the treatment of choice for
primary osseous sarcomas with comparable later reconstruc-
tive demands. Sometimes, the biopsy procedure may cause
structural instability and external casts, splints, or external
fixators are necessary. The method of choice for postresection
leg stabilization should at best be determined before biopsy.
If external fixators are planned for a definitive skeletal stabi-
lization, the montage may already be applied during biopsy
if the diagnosis is verified by a pathognomonic bone X-ray.
Specimen handling
If the resection is completed, the tumor and the tumor bed are
photographed and the specimen is removed. It is extremely
important to clearly mark the decisive anatomic landmarks
and the topographic orientation of the tumor in its previous
bed to allow unequivocal and exact determination of margins
by the pathologist. Optimally, the examining histopathologist
is present at this stage of the procedure. The surgeon has to
ensure that any identifying orientation markings on the tumor
are not shifted or torn off during transport.
Wound closure
Before wound closure, meticulous hemostasis and the place-
ment of sufficient closed suction drains are necessary. Skin
closure should be done in a multilayered fashion exerting

102
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
have already been mentioned above. In general, the plastic
surgical reconstruction follows the reconstructive ladder with
the lowest rung being the least invasive method (secondary
healing) and the highest rung representing customized chime-
ric multicomponent free flaps. Like in many other reconstruc-
tive problems, the best option for the individual patient must
be chosen regardless of whether it requires more complicated
surgery (“reconstructive elevator”).30–32
The following subsections demonstrate the vast diversity
of plastic surgical methods, also found elsewhere in this book
in detail. For sarcoma reconstruction, the surgeon has to keep
in mind that pre- or postoperative radiation or previous
chemotherapy can spoil his or her success rate, especially in
complicated microvascular reconstructions. The use of large
recipient vessels outside the radiation field, supple soft-tissue
closure, and as little foreign material as possible are proven
ways for successful surgery.
Soft tissue
Soft-tissue coverage for sarcoma reconstruction must always
be seen in the context of preoperative and adjuvant radio-
therapy. The goals are obliteration of dead space, closure
of large skin defects with tension-free wound closure,
preservation of thin but viable skin edges by supporting
them with voluminous muscle flaps, and to cushion exposed
bony prominences around the tibia, joints, or amputation
stumps.
Local and regional fasciocutaneous flaps are slightly supe-
rior to skin-grafted muscle transposition flaps (i.e., medial or
lateral gastrocnemius head or peroneus brevis) in terms of fast
wound healing and radiation resistance. They might be of
limited availability after large tumor resection. Local perfora-
tor flaps are very useful for primary reconstructions. However,
if the area was irradiated, the perforators in the field are less
reliable and extremely difficult to dissect due to fibrosis or
became very small and fragile. Furthermore, the skin quality
and elasticity is inferior for donor site closure in secondary
reconstructions with local flaps.
Useful pedicled regional flaps to cover defects in the thigh
may be harvested from the deep inferior epigastric artery
system of the lower abdomen (i.e., transverse rectus abdomi-
nus myocutaneous, vertical rectus abdominus myocutaneous,
deep inferior epigastric perforator, and rectus abdominis
muscle) or from the buttock area (superior gluteal artery
perforator and inferior gluteal artery perforator). The latter
may have a suitable rotation radius if isolated on their respec-
tive perforators (Case 4.3).
Microvascular free flaps from all over the body may be
used for lower extremity reconstruction and are chosen
according to the defect geometry and depth, location, and
functional requirements. For secondary reconstructions,
recipient vessels are rare or fragile, if the area was irradiated
and a preoperative angiogram is warranted. Sensate flaps (i.e.,
lateral arm flap) should be considered for weight-bearing
areas at the foot or on amputation stumps.
Neuromuscular unit
Resected main nerves can be microsurgically reconstructed
with multiple cable grafts from the sural nerve or other donor
sites according to the cross-section of the recipient nerve.
Indications for amputation
In selected cases, amputation of the leg must be considered
the best option for the patient despite very detailed imaging
techniques, modern oncologic resection strategies, advanced
sophisticated plastic reconstructions, and advances in radio-
logic and chemotherapeutic therapeutic regimens. Primary
amputations for treatment of lower extremity sarcomas are
necessary in less than 5% of all patients and in less than 15%
in recurrences while demonstrating a comparable long-term
survival.2–4
Amputations are chosen as an adequate primary therapy,
if significant medical comorbidities prevent the safe comple-
tion of a major tumor resection with immediate defect recon-
struction. Usually, these cases are very rare, and almost always
the reconstruction can be deferred to a secondary operation.
Modern advances in anesthesiology and intensive care medi-
cine usually allow long procedures to be performed safely.
The only exceptions where an immediate reconstruction must
be performed are immediate revascularization procedures in
cases with extensive main arterial involvement. Extensive
lower limb reconstruction procedures also have to be bal-
anced cautiously against amputation in para- or tetraplegic
patients or patients with severe cerebral impairment who are
bedridden for lifetime.
If the tumor demonstrates transmetatarsal growth, pene-
trates the interosseus membrane in the lower leg, already
shows locoregional dissemination (for example with rhabdo-
myosarcomas), or the patient presents with a very large and
extensively ulcerated tumor with circular leg involvement, an
amputation may be inevitable. Primary multicomponent
sarcomas in the proximal thigh may be treated best with an
amputation as well as extensive tumor recurrences after
exhaustion of all adjuvant or surgical modalities.
Uncontrollable chronic diseases that are not acceptable for
major (microvascular) procedures or render the preservation
of the sarcoma-infested extremity useless can make an ampu-
tation inevitable. Examples are open ulcers because of chronic
venous insufficiency or atherosclerotic occlusive disease in
the same leg, an ipsilateral unrelated tumor, or a history of
previous trauma with subsequent subclinical osteitis. The
latter could reactivate in the context of major surgery or
adjuvant therapy.
Furthermore, the predictable inability to reconstruct a
stable extremity and/or wounds that are not suitable for safe
conservative wound care and patient handling are an indica-
tion for amputation, if the full reconstructive spectrum has
been evaluated for leg salvage and a suitable solution was not
found. This might include the unavailability of relevant donor
sites for (microvascular) extremity reconstruction.
Lastly, patient preference in favor of amputation is very
rare after thorough information about modern reconstructive
possibilities but has to be respected in selected cases.
Reconstructive options for lower
extremity preservation
Plastic surgical involvement in sarcoma treatment already
begins during tumor resection. Several examples that demand
plastic surgical and microsurgical knowledge during skin
incision, tissue dissection, and neurovascular preparation

103
Reconstructive options for lower extremity preservation
techniques. However, a combination of the above with pedi-
cled or free vascularized bone may benefit the patient and
augment the therapeutic armamentarium. Therefore this
“orthoplastic approach”35 does not only refer to post-traumatic
reconstructions but is a fruitful strategy for oncologic plastic
surgery as well.
In selected cases, a variety of traditional techniques like
fibula-pro-tibia transfer require microsurgical dissection of
the pedicle (Fig. 4.3) or an orthopedic osteosynthesis in the
metaphyseal area may benefit from additional vascularized
bone from a composite flap to augment the construction. Very
useful flaps here are the latissimus-bone flap and the (para-)
scapular bone flap with a lateral and or medial scapular bone
segment of up to 11 × 3 cm that provides coverage or filling of
extensive soft-tissue defects or prosthetic material. For smaller
defects around the foot, composite flaps like the osteofascio-
cutaneous lateral arm flap are useful.36
Large defects of the long bones are more difficult to recon-
struct with autologous tissue in the lower extremity than in
the upper.37 This is due to the geometrical and size mismatch
of the largest human bone flaps, that is free fibula and vascu-
larized iliac crest (deep circumflex iliac artery flap). However,
vascularized bone is a vital, dynamic, growing, infection
resistant, and relatively radiation resistant tissue. The various
methods for single and double fibula reconstruction of exten-
sive long bone defects in the lower extremity are discussed
Meticulous technique and the use of an operative microscope
are paramount. In selected sarcoma resections that include
bone and nerves, the bone may be restabilized with shorten-
ing of the extremity. This scales down the soft-tissue defect,
facilitates wound closure, and can make primary nerve coap-
tation possible.
Depending on the muscular units that have to be resected,
muscle or tendon transfers may be performed primarily.
Biceps tendon or posterior tibial transfers are the most
common transfers in the lower extremity to reconstruct knee
extension and foot elevation, respectively (see Case 4.1).
Tenodeses may preserve muscular power in partially resected
compartments (i.e., adductors) and allow muscular stabiliza-
tion of joints. Of course, free functional muscle transfers (i.e.,
mm. gracilis and gastrocnemius)33 are very useful in young
patients with high neuroregenerative potential as well.
Skeletal reconstruction
Reconstruction of the skeleton after resection of soft-tissue
sarcomas involving bone secondarily and primary osseous
sarcomas are the main interdisciplinary field of orthopedic
and plastic surgeons. Expandable and non-expandable tumor
prostheses, Van Ness or Borggreve rotationplasty,34 resection
arthroplasties, distraction osteogenesis, segment transport, or
total joint replacements commonly belong to the orthopedic
Fig. 4.3  Historical overview of various fibula-pro-tibia techniques for lower leg reconstruction.
Hahn 1884
Wittek 1906
Codvilla 1909
Brandes 1913
Moszkowicz 1917
Stracker 1926
Davis 1944
Allgöwer 1963
Muller 1963
Blauth 1963
Dederich 1965
Ferrand 1966
Zanoli 1966
Ferrand 1966
Blauth 1971
Eckeu Kyambi 1975

104
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
vessel systems provide large, multilobed transplants with a
variety of different tissues for simultaneous soft-tissue and
skeletal reconstruction.49 Chimeric flaps further expand this
enormous variability (i.e., free fibula with ALT).
In selected cases, where amputation or segment amputa-
tion is inevitable, the distal limb segments are viable and
healthy. According to the spare-part principle of plastic
surgery, the tissue may be transferred as a composite fillet
flap, either pedicled or free microvascular, onto the amputa-
tion site providing length and suitable tissue quality for
coverage. Preservation or coaptation of the contained nerves
may achieve a sensate flap of excellent quality and skin
texture.
Postoperative care
Immediate postoperative care
A firm concept of postoperative care is very important follow-
ing biopsies, definitive sarcoma resection, and after any
reconstructive surgical procedures for a variety of reasons.
The postoperative protocol after incisional or excisional biop-
sies is focused on the prevention of hematoma and seroma
formation and thereby possible tumor spread. While meticu-
lous hemostasis and drainage placement is paramount (see
techniques section), postoperative fluid collections in the
resection bed and in tissue planes can be prevented effectively
by bed rest, elevation of the affected lower extremity, and
immobilization by external fixators or splints. Circular elastic
bandaging and compressive dressings are also helpful.
Most reconstructive procedures in sarcoma surgery with
larger lesions need defect closure with flaps of some kind.
Lower extremities that were reconstructed with local, regional,
or free flaps need to be positioned in a slightly elevated posi-
tion for 5–7 days to accommodate the circulation rearrange-
ments in the flap tissue and to prevent early venous congestion
in the transplanted tissue. Frequent flap perfusion monitoring
is paramount in the first days and ensures immediate inter-
vention should a pedicle thrombosis or hematoma occur.
Patients with neoadjuvant chemotherapy or preoperative
intra-arterial perfusion are at high risk for vascular complica-
tions in this context.
Following this period of elevation, orthostatic “flap train-
ing” can be initiated with lowering the reconstructed extrem-
ity for 5 min t.i.d. associated with external compression by
elastic bandaging. After this, the flap is clinically evaluated
and the procedure can be extended in increments of 5–15 min
daily over the next week until 1 h is accumulated. This allows
reasonable intervals for early gait training and mobilization
by stage-adapted physiotherapy.
Compressive bandaging should be replaced by custom-fit
compressive garments worn for at least 6 months for all soft-
tissue flap reconstructions of the lower extremity except pure
osseous flap reconstructions. Usually, garment wearing is
initiated when the sutures are removed and the wound is
healed.
Postoperative weight-bearing depends on the bony resec-
tion and reconstruction procedures that were performed, the
hardware used for osteosynthesis, and the bone quality. The
mobilization schedule should be determined exclusively by
the operating surgeon. Serial roentgenograms or CT-scans
elsewhere in this book and apply to sarcoma reconstruction
alike (Chapter 7).
In the context of adjuvant radiotherapy, avascular autolo-
gous or allogeneic bone grafts, with their high complication
rate of fracture, infection, slow integration, and creeping
substitution, should be used very carefully and only in
selected cases. When using these grafts, there should be
special emphasis on ample vascularization of the surrounding
soft-tissue bed and obliteration of any dead spaces around the
bone. This optimizes creeping substitution of the avascular
allograft and reduces the probability of graft exposure after
radiation.
Combination techniques using an avascular structural
allograft with a vascularized free fibula inside, as described
by Capanna, offer promising results especially for extensive
skeletal defects in young tumor patients (see Case 4.7).38,39
This hot-dog-like construct combines optimal vascularization
of the vascularized autologous fibula with the structural sta-
bility of the geometrically matched allograft “shell”. The
osteosynthetic stabilization of this construct over the length
of a long bone and in metaphyseal areas may be a compromise
as the vascular pedicle and vascularization of the inner fibula
must be preserved. Burring a trough into the allograft for
guiding the peroneal pedicle through the allograft cortex to
their recipient vessels has proven quite useful.39,40
Vascular surgery
Main arteries that need to be resected together with the tumor
should be reconstructed immediately by interpositional vein
grafts in the lower leg. Proximal to the knee, autologous vein
grafts may be too small and alloplastic material may be con-
sidered as an alternative for vessel replacement or extra-
anatomic bypasses. It is paramount to ensure a good soft-tissue
coverage for these materials to prevent exposure, which is
easier to achieve in the thigh than in the lower leg.
In selected cases, a temporary arteriovenous loop con-
nected to large-bore vessels proximal to the recipient area
offers large-diameter vascular access for microvascular anas-
tomosis distant to any previously scarred or irradiated area.
For the proximal thigh and groin area, even the contralateral
femoral vessels can be used as recipients for a cross-over
graft.41 If available, autologous vein grafts should be used for
vessel reconstruction. In selected cases with tumor-related
resection of main arteries, a simultaneous defect coverage and
vessel reconstruction can be provided by flow-through flaps
(i.e., anterolateral thigh (ALT), radial forearm, and free fibula).
Due to the high rate of venous graft occlusion for vein
reconstruction in oncologic patients, the procedure should be
done only in selected cases.42 One of the reasons for this might
be the use of longer vein grafts in oncologic surgery than in
trauma patients, which are more prone to thrombosis. Com-
pared to trauma cases, venous outflow compromise by inva-
sive tumor growth occurs more slowly and the dynamic
nature of the lower leg venous system almost always allows
the development of sufficient venous collaterals, if the affected
deep veins are resected.
Complex approaches
For complex defects, free microvascular composite flaps from
the subscapular, external iliac, or lateral circumflex femoral

105
Secondary procedures
during or after a possible radiotherapy to optimize the overall
result.
Despite adequate healing during the primary reconstruc-
tive phase, wound healing disturbances, fistulas, and incision
breakdowns may occur during the scheduled radiation cycles.
If the initial soft-tissue closure was supple enough, early
wound excision and secondary closure may suffice in minor
cases. However, larger skin breakdowns may lead to exposure
of functional structures like tendons, vessels, nerves, and
bones, which need to be covered urgently to prevent radiation
induced osteitis, vessel thrombosis, or tissue necrosis. Local
flap solutions are only possible, however, if the appropriate
vessels are still intact, as mentioned before.
With the radiation cycles completed, many patients experi-
ence fibrosis, scar formation, contractures, and tendon adhe-
sions. Early function-improving procedures include tenolyses,
contracture and scar releases, serial excisions, or tendon
transfers that were not possible or justified primarily. It is
often very difficult to evaluate during tumor resection, if any
remaining musculature or nerves fascicles will suffice for an
adequate basic motor function. A typical example for a sec-
ondary procedure like this is the posterior tibial tendon
transfer for a clinical drop-foot caused by a muscular or neural
insufficiency of the peroneal compartment. Neuroma forma-
tion or nerve entrapments in irradiated and fibrotic tissue
should be approached with desensitization and conservative
therapy first, but frequently may require early operative
neurolyses.
Contour improving procedures of bulky transferred tissue
should be performed not earlier than 6 months to be less
independent from the vascular pedicle. They follow standard
plastic surgical debulking techniques like direct sequential
flap excision, tangential subcutaneous thinning, tangential
thinning, and secondary resurfacing with split- or full-
thickness skin grafts in muscle flaps or aspiration lipectomy.
The same time frame applies to secondary procedures for
forming amputation stumps. However, additive procedures
on amputated legs like cushioning and stump lengthening by
local and free flaps or sensitization by transfer of neurotized
transplants can be planned earlier than 6 months after the
amputation.
Early secondary procedures – skeleton
As mentioned above, skeletal reconstruction and stabilization
should be performed as completely as possible during the
primary reconstructive stage. Usually, orthopedic prosthetic
joint or long bone replacements do not need any secondary
surgery if the initial montage demonstrated uneventful osteo-
integration. Prosthetic replacement is mostly used in primary
osseous sarcomas with large skeletal defects after resection.
However, infection, mechanical failure, and loosening are
among the most common prosthetic complications in the
context of radio- and chemotherapy. Major revision surgery is
therefore needed, which is described in the pertinent ortho-
pedic literature.
If plastic surgical reconstruction of the lower limb skeleton
was performed by free autologous bone grafts, vascular-
ized bone transplants, avascular allogeneic bone grafts, or
combinations of the above, osseous healing is often slow in
sarcoma patients, especially if the radiation field encompasses
the zone of skeletal reconstruction. Therefore augmentation
help in determination of the bone healing and regained func-
tional stability of the extremity.
Oncologic postoperative care and follow-up
Patients after sarcoma resection with adequate margins and
R0-situation need postoperative adjuvant radiation therapy
under most circumstances, especially in tumors that are
classified as high-grade (G2/G3). Only superficial, low-grade
lesions with tumor-free wide margins may be treated with
wide resection only. The radiation oncologists start with the
therapy according to the appropriate treatment protocols
established by the tumor board decision as soon as the wound
is healed. If any unexpected oncologically relevant factors
occurred during resection or reconstruction (inappropriate or
positive margins, vessel invasions, histology, etc.), the new
findings should be presented in the tumor board as the treat-
ment plan needs to be revised accordingly. This is also true
for any late follow-up findings, which imply a change in the
normal course of healing by emerging local recurrences or
distant metastases.
The modalities or patient follow-up after completion of
resection and possible adjuvant treatment are not clearly
defined in the literature. The following investigations are well
accepted in the current literature:
■ Thoracic CT-scan. Distant metastases in lower extremity
sarcomas almost exclusively occur through hematogenous
spread into the lung with only a few exceptions (see
above). It should be repeated every 3 months.
■ Contrast-enhanced MRI of the primary tumor site every 3
months. This should always be evaluated by or together
with the surgeons. MRI is also the diagnostic method of
choice for evaluating lymphatic spread if applicable.
However, MRI criteria of tumor stability or progression
may not correlate with the tumor status correctly.
■ Serial radiographs of the primary tumor location at least
every 6 months if the skeleton was affected by the
primary tumor or included in resection or reconstruction.
The osteointegration of prosthetic material, bony healing,
bone grafts, or transplants are controlled more frequently
in the postoperative period anyway. A CT scan should be
performed if the information by the plain radiograph is
insufficient or suspicious findings occur.
■ New imaging techniques evaluating the metabolic
activity of tumor material like PET (or PET-CT) or
magnetic resonance spectroscopy (MRS) are promising.
While this is a fast developing field and the numbers of
tracers are increasing, these methods are increasingly
accurate in controlling preoperative response to adjuvant
therapy and postoperative follow-up. No commonly
accepted follow-up schedule exists for sarcomas so far,
and patients should be integrated into suitable studies.
Secondary procedures
Early secondary procedures – soft tissue
After the initial tumor resection and extremity reconstruction
is performed successfully and the wounds are healed, in the
majority of cases plastic surgical therapy must continue

106
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
Late secondary procedures after implantation of major
hardware like modular prostheses or total joint replacements
may include hardware exchange due to wear, mechanical
failure, or loosening.
Long-term sarcoma survivors with a previous lower limb
amputation may experience stump problems like retracted
soft tissue with insufficient soft-tissue coverage of the bone,
skin folds that impair proper wear of the prosthesis, painful
neuromas, and trophic skin changes. Many patients are very
experienced with their prosthesis and ask for specific plastic
surgical stump corrections. In selected cases, this might
include microvascular free flap transfers, preferably with
sensate flaps.
Outcomes, prognosis, and
complications
Outcomes and prognosis
Several specialized evaluation scores do exist (Musculoskel-
etal Tumor Society (MSTS),45 Toronto Extremity Salvage Score
(TESS),46 European Organization for Research and Treatment
of Cancer (EORTC QLQ-C30)) that rate various sets of subjec-
tive and objective parameters for functionality, quality-of-life,
emotional, and social factors.47,48
Soft-tissue sarcomas
The current age-adjusted death rate for soft-tissue sarcomas
is 1.3 per 100 000/year, based on data between 2001 and 2005.1
A recent series, from the Memorial Sloan Kettering Cancer
Center (MSKCC), of 1706 patients with primary and second-
ary soft-tissue sarcomas of the extremities with a mean
follow-up of 55 months demonstrated a 5-year disease-specific
survival rate of 85% in patients treated between 1997 and
2001. This number did not differ significantly from the sur-
vival rate in the previously treated patients from this group.
The same was true for the subset of high-risk patients in this
group with a 5-year disease-specific survival rate of 61% in
those treated between 1997 and 2001. This indicates that the
prognosis for patients with extremity soft-tissue sarcomas has
not changed over the last 20 years. Throughout this period,
tumor depth, size, grade, margins, presentation status, loca-
tion (proximal vs. distal), and certain histopathologic subtypes
as well as patient age remained significant prognostic factors
(Table 4.5).1
Steinau et al. report about 85 soft-tissue sarcomas in the
lower extremity among 744 sarcoma patients between 1980
and 1996. Mean age at presentation was 42.9 years (range 6–80
years), with 38 patients being previously operated elsewhere.
Eighteen patients had 2–9 recurrences. Still, in 81 patients
(95.3%) an R0-resection with curative intention could be per-
formed, whereas 4 patients underwent a palliative resection
due to multilocular distant metastases. In 41/81 patients
extensive tissue defects resulted after the resection and 17
local and 24 free flaps were needed for closure. Thirteen
patients received a simultaneous tendon transfer with defect
closure to improve their gait. In 18 patients with local skeletal
infiltration, special plastic surgical bone reconstructions,
conventional partial foot amputations, or atypical hindfoot
amputations were done. All of these patients received
of previously inserted bone transplants or revision of pseud-
arthroses with corticocancellous bone packing is quite often
necessary – especially in non-vascularized grafts. At this stage,
the osteosynthesis may also be changed to a more stable and
definitive method if the primary one has failed.
The microvascular medial femoral condyle corticoperios-
teal flap may be a useful tool to provide vascularity and
osteogenic potential for recalcitrant pseudarthroses in a previ-
ously irradiated field.43,44
Sarcoma-related partial joint resections in the weight-
bearing lower extremity may be critical. Painless function
with an acceptable range of motion must be the reconstructive
goal. Especially after partial joint resections or resection
arthroplasties, the functional outcome often cannot be ade-
quately assessed until complete mobilization of the patient
has taken place. If joint salvage surgery was not successful
primarily, resulting in an unstable or painful joint with a
severely impaired range of motion, secondary arthroplasties,
joint replacement surgery, or arthrodeses may be necessary.
If the limb-preserving surgery consisted of a shortening of
the limb, secondary distraction osteogenesis for extremity
length adaptation can now be performed with all the soft
tissue healed and the radiation therapy completed. However,
docking failures are more frequent in irradiated patients.
Corticocancellous augmentation is then needed to achieve
stability.
Late secondary procedures
The number of patients that are long-term survivors after
successful sarcoma therapy in the lower extremity is con-
stantly increasing. A considerable number of them need late
secondary reconstructions or surgical corrections of their
reconstructed leg. The plastic surgical therapy at this stage
aims to correct the sequelae of the previous interdisciplinary
plastic surgical, radiologic, and orthopedic therapy. Though
not life- or limb-saving anymore, these procedures are never-
theless important to help the patients complete their personal
and social coping after the disease and to improve quality of
life.
Scar releases and flap debulkings because of functional and
aesthetic reasons that began in the early secondary stage fre-
quently need revisions for several years. Irradiation may
leave a hard, constrictive, and fibrotic soft-tissue integument
behind, which may be painful in rest and in motion or while
wearing clothing and shoes. If postirradiation ulcers and
unstable scars further deteriorate the situation, the plastic
surgeon must be aware of late local recurrences and second-
ary malignancies in the affected area. Excision of the lesions
or the constricted scarred skin and transfer of unimpaired
healthy tissue by local, regional, or free tissue transfer can
improve the patient’s quality of life considerably. Of course,
any excised tissue from these areas must be evaluated
histopathologically.
Peripheral neuropathies are less common after irradia-
tion but more common after chemotherapy and may cause
disabling chronic pain to the patient. Frequently, the nerve
is relatively healthy, but entrapped and fixed by surround-
ing dense, fibrotic, and irradiated tissue. Adequate therapy
consists of careful neurolysis, rerouting, and wrapping
of the nerve in well-vascularized tissue by microsurgical
methods.

107
Outcomes, prognosis, and complications
patients having undergone limb salvage surgery with later
local recurrence had a slightly better survival rate than
primarily amputated patients (37% vs. 31% at 5 years).11,12
Marulanda et al. stated that for osteosarcoma patients there is
no difference in survival between amputations and properly
performed limb-salvaging procedures.50
Carty et al. reported their results after LSS of 20 intra-
articular knee osteosarcoma patients and their reconstruction
with endoprostheses. Evaluation was done by MSTS and
TESS scores, and moderate to high function was achieved.48
A Norwegian study, involving 118 patients with osteosar-
comas or Ewing’s sarcoma in the extremities, evaluated the
long-term functional outcome at a minimum of 5 years after
treatment. The function was evaluated with the MSTS and
TESS scores while quality of life was assessed using the Short
Form-36 (SF-36). The mean age at follow-up was 31 years
(15–57 years), and the mean follow-up was 13 years (6–22
years). A total of 67 patients (57%) initially had limb-sparing
surgery, but 4 had a secondary amputation. The median MSTS
score was 70% (17–100%), and the median TESS was 89%
(43–100%). The amputees had a significantly lower MSTS
score than those with limb-sparing surgery (p < 0.001), but
there was no difference for the TESS. Tumor localization
above the knee level resulted in significantly lower MSTS and
TESS scores. There were no significant differences in quality
of life between amputees and those with LSS except in phys-
ical functioning. In a multivariate analysis, amputation, tumor
location above the knee, and having muscular pain were
associated with low physical function. Most of the bone tumor
survivors managed well after adjustment to their physical
limitations. A total of 105 patients were able to work and had
an overall good quality of life.51
Complications – management of
recurrent disease
If local tumor recurrences are present, they are usually found
quite early if the patient is compliant according to his or her
individualized orthopedic shoe and inlay adaptions and
finally achieved (with and without these shoes) a better gait
and ability to do sports, in comparison with patients who
received lower leg prostheses. In 2 patients, a transtibial
amputation was inevitable. In this group of 85 patients, a
mean survival of 132 months and a 5-year survival rate of 62%
was found.3
The Finnish experience, with 73 patients with lower limb
soft-tissue sarcomas who received limb-salvage surgery,
reports a 5-year local recurrence-free survival rate of 82%, a
metastasis-free survival of 59%, a disease-free survival of 56%,
and a disease-specific overall survival of 70% over a follow-up
time of 65.9 months. Three-quarters of the patients were able
to walk normally or had only minor walking impairment.
They emphasize that microsurgery is an essential part of
modern tumor surgery.49 Long-term survivors have a higher
probability of experiencing both sequelae of their primary
plastic surgical treatment (i.e., contractures, bulky flaps, and
unstable scars) and secondary malignomas (i.e., postradiation
angiosarcomas).
A large study from an interdisciplinary sarcoma center in
Germany had a mean follow-up of 36 months for 167 patients
with extremity liposarcomas. Over this time, only 5 (3%) of
the patients had to undergo amputation throughout this
period. A clear margin R0-resection could be achieved in 158
patients. The authors report an overall 5-year survival rate of
79%, though the study collective was biased in favor of exten-
sive and previously operated cases due to the reference center
status of the clinic. Patients with primary tumors had a 5-year
survival rate of 90%, and an overall number of 37 local recur-
rences were found. The myxoid liposarcoma was responsible
for most recurrences. Patients with recurrent tumors had a
5-year survival rate of 69%.26
Bone sarcomas
The European Osteosarcoma Intergroup reports a 57% 5-year
survival rate in a patient group of 202 patients with a 49–85%
limb salvage rate. An important finding of this study was that
Table 4.5  Prognostic factors in soft-tissue sarcoma therapy
Factor
Distant recurrence-
free survival
Local recurrence-
free survival
Relapse-free
survival
Disease-specific
survival
Age >50 years
−
−
−
−
Recurrent sarcoma
−
−
−
−
Size >5 cm
−
−
−
−
Deep location
−
−
High−grade
−
−
−
Proximal position
−
Histology
Fibrosarcoma
−
Leiomyosarcoma
−
−
−
Positive microscopic margin
−
−
−
−
Time period of treatment
Minus symbols indicate an independent adverse prognostic factor, and blank fields indicate a non-independent prognostic factor.
(Adapted from Weitz J, Antonescu CR, Brennan MF. Localized extremity soft-tissue sarcoma: improved knowledge with unchanged survival over time. J Clin Oncol.
2003;21:2719–2725.)