Two principles are recognized in limb-salvage surgery—careful, adequate excision of the tumor followed by optimal functional reconstruction of the limb. Patient lifestyle and expectations should be carefully considered when selecting the reconstructive procedure. Most patients can be successfully treated with limb-salvage procedures, but in some patients with stage IIB tumors, only amputation can minimize the likelihood of recurrence. In addition, amputation may still be needed if the limb-salvage procedure is followed by recurrence, deep infection, or vascular insufficiency.

RECONSTRUCTION AFTER LIMB-SALVAGE RESECTION

After excision of a soft tissue sarcoma, the defect is usually reconstructed with a local tissue transfer to obliterate dead space or a temporary vacuum drain is used to avoid wound complications. Large soft tissue reconstructions after excisions may involve the transfer or rotation of a muscle or skin flap, split-thickness skin grafts, or, in rare situations, a free vascularized muscle or cutaneous muscle flap.

When half of the joint or the whole joint is resected, the reconstructive procedures used are primarily arthroplasties (see Plates 6-31 to 6-33).

Arthroplasty. Successful arthroplasty depends on surrounding musculature that has good power, vasculature, and innervation. The optimal result of arthroplasty is a painless, stable joint with good range of motion.

Arthroplasty may be achieved with (1) implantation of a prosthetic joint or partial joint (in the hip or shoulder) (see Plate 6-31), (2) transplantation of an articulating bone allograft, or (3) a composite technique—a combination of prosthesis plus bone allograft (see Plate 6-31). Use of bone allografts offer the advantage of a biologic implant that has the potential for gradual incorporation and soft tissue attachment. However, allografts are associated with a high rate of complications such as infection, fracture, and nonunion at the graft-host junction. The risk of a serious complication necessitating removal of the graft or another operative procedure, including amputation, is as high as 30%. In the hip joint the acetabulum can be reconstructed with a cage-type acetabular prosthesis in many cases. Arthroplasty with a combination of prosthesis and bone allograft (i.e., an allograft prosthetic composite) can be a useful reconstruction particularly in the proximal humerus, allowing for improved elevation and decreased dislocation compared with a prosthetic alone. In the proximal tibia an allograft prosthetic composite can lead to improved patellar tendon insertion and thus improved knee extension and strength (see Plate 6-31).