Modern Plastic Surgery, 2013, 3, 134-141 Published Online October 2013 (
Single Stage Oncologic Resection and Reconstruction: A
Step toward Development of Sarcoma Service in Resource
Constrained Country*
Haroon ur Rashid1, Kashif Abbas2#, Masood Umer1
1The Aga Khan University Hospital, Karachi, Pakistan; 2Islam Medical and Dental College, Sialkot, Pakistan.
Received February 28th, 2013; revised March 27th, 2013; accepted April 5th, 2013
Copyright © 2013 Haroon ur Rashid et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Tumor free-margin surgical resection remains the single most important treatment in the curative therapy of muscu-
loskeletal tumor of limbs. Refinements in surgical techniques have led to increased function preservation and limb sal-
vage. Patients and Methods: The records of patients (n = 24) who underwent microsurgical soft tissue reconstruction
subsequent to resection of limb tumour during the period 2006 to 2011 were reviewed. Primary outcome i.e. uptake of
the flap was evaluated. Perioperative morbidities were also noted in cluding donor as well as recipient site complication s.
Assessment of Functional outcome (Musculoskeletal Tumor Society score, MSTS) local recurrence, free survival, and
disease-specific survival was also made. Results: Twenty four patients (age range: 7 - 72 years) who have undergone
tumor resection followed by flap coverage were identified. Lower limb reconstruction outnumbered upper limb by 6:1.
Complications included, one complete failure of free vascularized iliac crest flap done for reconstruction of a heel de-
fect. One of the patients had secondary hemorrhage 10 days after surgery. Another patient with internal hemipelvec-
tomy for Ewing’s sarcoma had a dura puncture during resection of sacrum. Partial epidermal necrosis was evident in
four cases. Eighty three percent of the patients remained alive (n = 20), 19 of whom currently have no evidence of dis-
ease (NED) Disease recurrence was noted in three patients. Overall MSTS score was 73.5%. Conclusion: The micro-
surgical repair of defects is a reliable option that, though not free of complications, is necessary in selected cases. The
procedure enables both adequate oncosurgical resection and function preservation.
Keywords: Musculoskeletal Tumor; Reconstruction; Flap
1. Introduction
Survival rates after limb salvage surgery have improved
greatly over the past 20 years, primarily because of new
techniques in soft tissue reconstruction. The required
surgical margin of 2 - 3 cm of tumor free tissue fre-
quently causes large soft tissue defects. Local or free
flaps are often required to achieve tension free wound
closure or to reconstruct tissue defects.
The basic principles in soft tissue vascular anatomy
and bony reconstruction have long been established. In
the last two decades treatment of soft tissue defects has
become commonly available and reliable. Today, using a
combination of surgery and radiotherapy, better func-
tional results are achieved with equal rates of local con-
A viable yet painful, stiff or insensate limb hardly
serves the patient; the instinctive desire on both the pa-
tient and physicians’ part to save a limb at all costs must
be tempered by the expected long-term functional result.
The most heroic and beautifully performed vascular and
bony reconstructions are wasted without concomitant
coverage of these repairs [1,2].
Modern treatment consists of multidisciplinary team
approach; orthopedic oncologist resects the tumor and
reconstructs the skeletal defect which is followed by the
second team doing the soft tissue reconstruction work
In advanced cases and delayed presentations, limb
salvage is impossible, and sometimes amputation is un-
avoidable [4]. For very proximal shoulder or pelvic gir-
dle resections, soft tissue reconstruction may not be pos-
*Disclosure: No benefits in any form have been received or will be
received related directly or indirectly to the subject of this article.
#Corresponding author.
Copyright © 2013 SciRes. MPS
Single Stage Oncologic Resection and Reconstruction: A Step toward Development of
Sarcoma Service in Resource Constrained Country 135
sible without a rotational or free flap [5].
The aim of the study is to evaluate the results of our
cases of microvascular reconstruction done for extensive
bone and soft tissue defects after tumor resection.
2. Materials and Methods
This is a retrospective review of twenty four patients who
underwent reconstruction of oncologic defects by a sin-
gle team of two surgeons at a single institution from
2006-2011. All patients with tumors of extremities re-
quiring sof t tissue reconstr uction for woun d closure were
included. We excluded cases that required split or full
thickness skin grafting as a sole means of wound cover-
age. Medical record number are retrieved through surgi-
cal team database and demographics and further details
were reviewed through confidential files and hospital
based software called Patient Care Inquiry (PCI), con-
taining patient records of hospital visits. Primary out-
come i.e. uptakes of the flap were evaluated. Periopera-
tive morbidities were also noted including donor as well
as recipient site complications. The Musculoskeletal tu-
mor society (MSTS) score is a clinical scored system
assessing pain, function, and emotional acceptance in
patients for upper and lower extremities. Patients with
lower extremity reconstructions were also evaluated with
regard to walking ability, gait, and the use of walking
aids. Patients with upper extremity reconstructions were
evaluated for manual dexterity, hand positioning, and
lifting ability.
Surgical Team Protocol
Our surgery team comprises of two surgeons each spe-
cialized in tumor surgery and soft tissue reconstru ction.
All surgeries were done under general anesthesia.
Preoperative dose of Tranexamic acid 1 g (to reduce
post-operative blood loss) and cefazolin 1 gm is a routine
at the time of induction. Most of the surgeries below
mid-thigh level were done with tourniquet. Reconstruc-
tion followed immediately after tumor resection and was
done by the second surgeon with new sets of instruments.
Microsurgical aids were used where required. In three
cases of vascularized fibula, the procedure (tumor resec-
tion and reconstruction) was started simultaneously with
different set of instruments and scrubbed personnel to
minimize overall surgical duration.
Postoperative flap monitoring was done on hourly ba-
sis for initial 12 hours followed by 4 hourly monitoring.
Initial dressing change is done after 3 days and patients
are usually discharged after 5 days. Outpatient follow up
is weekly for first 3 weeks followed by monthly visit for
next 3 months. Patients are then followed up each quarter
for next 5 years. Patient living in remote cities were fol-
lowed on phone and mail.
3. Results
Twenty four patients were identified who have under-
gone tumor resection followed by flap coverage. There
were thirteen males (54%) and 11 females (46%). Mean
age was 29 years (7 - 72 year s), reflecting mix population
of diverse age group. Pathologic diagnosis of osteosar-
coma was present in 10 patients (42%) followed by 4
patients (17%) with soft tissue sarcoma, 3 patients (12%)
with Ewing sarcoma and squamous cell carcinoma of
extremities each, 2 (8%) with malignant melanoma of
extremities, one (4%) each of chondrosarcoma and giant
cell tumor. Tissue diagnosis was available in all patients
preoperatively. Lower limb reconstruction (88%) out-
numbered upper limb by 6:1. Eighty three percent of the
patients remained alive (n = 20), 19 of whom currently
have no evidence of disease (NED) Disease recurrence
was noted in three patients (13%), two patients under-
went wide margin resection for malignant melanoma,
both of which had recurrence within 2 years. A more
radical procedure in the form of forearm amputation was
done in one and the second patient refused any further
intervention and was subsequently lost to follow. An-
other patient with pleomorphic sarcoma of the proximal
tibia also had recurrence of disease, remote from the site
of surgery within 6 months; he also lo st to follow subse-
quently. One patient died of metastatic disease and an-
other patient with ewing sarcoma of pelvis died during
the course of her treatment after 12 months of surgery
(Table 1).
Complications included, one complete failure of free
vascularized iliac crest flap done for reconstruction of a
heel defect. This was subsequently managed with vac-
uum dressing and secondary wound closure. Another
patient had secondary hemorrhage 10 days after surgery.
Reconstruction involved in this case was coverage of
post external hemipelvectomy wound defect with free
flap harvested from amputated limb and anastomosed
with external iliac vessels. Patient was rushed to opera-
tive room due to expanding hematoma and drop in he-
moglobin. Intraoperative finding were consistent with
generalized ooze, thus wound was closed over drains; the
flap survived without any further complication. Another
patient with internal hemipelvectomy for Ewing’s sar-
coma had a dura puncture during resection of sacrum for
which a rectus abdominus flap and lumbar drain was
placed, postoperative recovery was uneventful and the
drain was removed af t e r 5 days (Table 2).
Partial epidermal necrosis was evident in four cases
whereas wound infection was observed in three patients.
4. Discussion
The goal of limb salvage surgery is to obtain safe surgi-
cal margins, preserving length and function. Simultane-
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Single Stage Oncologic Resection and Reconstruction: A Step toward Development of
Sarcoma Service in Resource Constrained Country
Copyright © 2013 SciRes. MPS
Table 1. Patient demographics.
Gender Age
(years) Site Biopsy Surgery Flap
Status at
last follow
up Complication Recurrence Flap
1 Male 65 Right foot Malignant
Wide margin
excision + lymph
node dissection
artery flap
24 monthsNil
after 2
8 × 5 cm72
2 Female 64 Right wrist Malignant
Wide margin
excision + lymph
node dissection
artery flap
18 monthsNil
years after
10 × 6 cm60
3 Male 37
Squamous cell
with wide
margins excision
dorsi flap +
months Died Partial
necrosis No 18 × 10 cm65
4 Male 28 Distal leg Malignant
Wide margin
excision and
tendo Achilles
Posterior tibial
island flap 30
months NED Nil Nil 12 × 6 cm78
5 Male 28 Left knee
Fibrosarcoma on
the background
of dermatomfi-
Wide margin
excision Sural artery
flap 38
months NED Nil Nil 10 × 5 cm82
6 Male 44 Right heel Squamous cell
Wide margin
excision + tendo
flap 20
months NED Nil Nil 8 × 4 cm86
7 Male 40 Right neck
of femur Osteogenic
sarcoma Hindquarter
amputation Fillet flap 34
months NED Secondary
hemorrhage Nil 20 × 14 cm68
8 Female 13 Left
sarcoma Wid e margin
excision Sural artery
flap 24
months NED Nil Nil 9 × 5 cm84
9 Female 19 Right
sarcoma Wid e margin
excision Tibialization +
sural artery flap24
months NED Nil Nil 10 × 5 cm86
10 Male 37 Left
sarcoma Wid e margin
excision Gastrocnemius
flap + STSG6 monthsRecurrence:
lost to
follow upNil
mid thigh
8 × 5 cm78
11 Male 58 Left
leiomyosarcoma Wide margin
fibular flap
months NED Nil Nil 14 × 6 cm80
12 Male 44 Right
mass Chondrosarcoma Forequarter
amputation Fillet flap 36
months NED Wound
infection Nil 14 × 8 cm70
13 Female 10 Right ilium
mass Ewing
sarcoma Internal
muscle flap
months DIED Epidermal
necrosis Nil 8 × 6 cm65
Single Stage Oncologic Resection and Reconstruction: A Step toward Development of
Sarcoma Service in Resource Constrained Country 137
14 Female 20 Calcaneum
mass Osteogenic
sarcoma WME Free iliac crest
flap 32 NED Flap failure Nil 6 × 4 cm75
15 Female 20 Iliac crest
mass Ewing
sarcoma Internal
hemipelvectomy Rectus
abdominus fla p6 NED
necrosis +
puncture +
sciatic palsy
8 × 6 cm68
16 Male 14 Iliac Mass Ewing
Sarcoma Internal
hemipelvectomy Rectus
abdominus fla p6 NED Nil 8 × 6 cm72
17 Male 17 Right
tibia Osteosarcoma Wide margin
excision Sural artery
flap 14 NED
nonuncion 8 × 4 cm82
18 Female 24
Giant cell tumor Extra articular
resection Gastrocnemius
flap 24 NED
Flap failure/
sural flap/
dorsi flap
6 × 4 cm
8 × 4 cm
14 × 8 cm
19 Male 38 Right tibia Squamous cell
carcinoma of
right leg
Wide margin
excision Free latissimus
dorsi flap 6 NED
healed by
16 × 10
cm 78
20 Female 20 Left Distal
Mass Osteosarcoma Extraarticular
resection of knee
dorsi flap
20 NED
Initial wound
7 × 4 cm
12 × 7 cm
21 Female 14 Distal
mass Osteosarcoma Wide margin
excision Vascularized
fibula 14 NED No
island 72
22 Female 15 Right mid
tibia Osteosarcoma Wide margin
resection Vascularized
fibula 10 NED No
island 70
23 Female 13 Right mid
mass Osteosarcoma Wide margin
resection Vascularized
fibula 6 NED No
island 72
24 Male 12 Distal
lesion Osteosarcoma Wide margin
resection Vascularized
fibula 10 NED No
island 68
Table 2. Peripoperative complications (n = 27 flaps in 24
Death 0
Flap failure 3
Recipient site Morbidity
Wound breakdown 4
Seroma/hematoma 3
Hemorrhage 1
Infection 3
Poor graft uptak e 1
Dura puncture 1
ous tumor resection and soft tissue reconstruction have
obvious funct ional benefi t s [ 6] .
Selection of flaps varies with location of primary dis-
ease and extent of resection. Pedicle based flaps are al-
ways preferred over free flaps. Gastrocnemius muscle
flap is a salvage option for soft tissue reconstruction
around knee joint and is also h elpful in providing pliable
tissue cushion around neurovascular structures. The me-
dial or lateral heads of the gastrocnemius muscle can be
expended with little or no deficit when walking or in
normal running [7].
In our series, gastrocnemius flaps were done in two
patients after extra-articular resection of knee joint in
order to cover implants and prevent overlying skin break-
down. Both of these patients had epidermal necrosis and
subsequent dehiscence of wound within two weeks of
Copyright © 2013 SciRes. MPS
Single Stage Oncologic Resection and Reconstruction: A Step toward Development of
Sarcoma Service in Resource Constrained Country
index surgery due to excessive undermining of skin flaps
for tumor resection. Free myocutaneous latissimus dorsi
flap was done to cover the defect in first patient and had
an uneventful postoperative recovery. In the second pa-
tient, sural artery pedicle flap was done initially which
failed gradually within 3 weeks; this was followed by a
free latissimus dorsi flap, which proved to be the final
procedure in this patient. Third gastrocnemius flap was
done for coverage of wound defect in popliteal fossa to
provide cushion around neurovascular structure. Wound
healing was uneventful in this patient.
In a study by Liu T et al, group with the transposition
of medial gastrocnemius muscle flap, local skin necrosis
occurred in 2 (5.7%), and prosthesis deep infection oc-
curred in 1 (2.9%). In the group without the transpositio n
of medial gastrocnemius muscle flap, subctaneous he-
matocele, and effusion occurred in 10.0%, wound infec-
tion occurred in 4 (13.3%), 1 cured and the other 3 de-
veloped prosthesis deep infection.There was significant
difference in the rate of local complications (P < 0.05).
There was significant difference in function assessment
between the 2 groups (P < 0.05). Results of patients in
our study was similar, although on a low scale, both of
our patient with extra articular resection and prosthetic
reconstruction, epiderma necrosis did not result in pros-
thetic deep infection due to cushion provided by gas-
trocnemius flap [8].
For decades, rectus abdominis flap has been used to
reconstruct breast defects, primarily as a pedicled flap
based on superior epigastric artery. While using inferior
epigastric artery as a pedicle, flap can be used to cover
upper part of thigh especially in cases of hemipelvec-
tomy where the flaps are so thinned out that wound de-
hiscence is likely, resulting in direct exposure of under-
lying neurovascular structures after tumour resection.
The flap provides healthy muscle, with or without a skin
paddle that can be used to replace soft tissue bulk and is
easy to perform and does not require microsurgical tech-
nique [9,10]. In our series only muscular portion of the
flap were used for soft tissue cushion. Rectus abdominis
flap was done in three patients who underwent internal
hemipelvectomy for pelvic tumor; one of them developed
wound dehiscence following epidermal necrosis. Her
wound was managed conservatively with dressings and
healed with secondary intention (Figure 1).
The concept of spare part surgery is also prevalent in
musculoskeletal oncology [11,12]. Reconstruction of the
defects is done using amputated limbs, myocutaneous
(a) (b)
(c) (d)
Figure 1. (a) Intraoperative photograph hemipelvectomy showing thin flap and nerves; (b) Nerves covered with rectus ab-
dominis muscle flap; (c) Early postoperative photograph showing epidermal necrosis; (d) Full thickness necrosis over rectus
abdominis musle cushion.
Copyright © 2013 SciRes. MPS
Single Stage Oncologic Resection and Reconstruction: A Step toward Development of
Sarcoma Service in Resource Constrained Country 139
component is harvested over main vessels from the am-
putated limb and is anastomosed with recipient vessel.
We have used same type of reconstruction in two patients,
one with forequarter amputation and another with exter-
nal hemipelvectomy. Both patients had good take of flap
in the recipient region.
Seven patients had soft tissue sarcomas for which all
of them underwent wide margin excision followed by
reconstruction with pedicled flaps in all except one in
whom free lattissimus dorsi flap was done. Two patients
among this group had malignant melanoma of upper and
lower limb each. First patient was 65 years of age with
heel tumor, cardiac arrythmias and ejection fraction of
25%. Flap failure was a concern due to age and circula-
tory compromise but fortunately flap survived. In this
case Breslow thickness of 13 mm was noted and a closest
positive margin was 0.5 cm away. Recurrence noted in
the form of a nodule away from the surgical site after two
years. Excision of lesion with repeat biopsy was consis-
tent with malignant melanoma. It is evident from the
literature that melanoma of lower li mb carries poor prog-
nosis than upper limb disease [13]. In second patient with
melanoma of wrist which was excised, axillary lymph
node clearance was done. Initial wound healing and re-
covery was satisfactory. Resected mass was a margin
positive at final histopathology with no nodal involve-
ment. Re excision was offered which was denied. Dis-
ease recurred at the surgical site in the form of small le-
sion after one and half year and thus more radical proce-
dure in the form of forearm amputation was done.
Vascularized fibula was done in six patients; five of
them had osteogenic sarcoma and remaining one had
pleomorphic sarcoma of forearm for which osteocutane-
ous free fibular flap was done to reconstruct the radius.
Four patients had onlay grafting of vascularized fibula to
augment biological reconstruction with autograft and
autoclaved bone. One patient had it done for intercalary
defect reconstruction. Viab ility of flap was checked with
bone scan after 2 weeks. Tracer uptake by fibula was
evident in all 6 cases. Union is no ticed in all cases. Three
out of five patients with lower limb reconstruction are
ambulating fu ll weight bearing witho ut support, wher e as
remaining two are still using walking aid (Figure 2).
Overall functional outcome was assessed using Mus-
culoskeletal tumor society (MSTS) score. In our study
mean score was 73.5% (Table 3). Reduced functional
(a) (b) (c)
(d) (e) (f)
(g) (h)
Figure 2. (a) and (b) Properative radiograph and MRI showing proximal tibia lesion; (c) Specimen radiograph; (d) Intraop-
erative picture showing remaining proximal tibia with tuberosity and sural pedical; (e) Biologic reconstruction with vascu-
larized fibula and sural flap; (f) Post operative and 2 weeks post operative picture; (g) Thirty months follow up radiograph;
(h) Thiry months follow up clinical photograph.
Copyright © 2013 SciRes. MPS
Single Stage Oncologic Resection and Reconstruction: A Step toward Development of
Sarcoma Service in Resource Constrained Country
Table 3. Comparision of our study and that of the other
Study Number of
patients MSTS score (%)
Niimi R. et al. [14] 63 81
Li J. et al. [15] 4 91.7
Payne C. E. et al. [16] 113 87
Funovics P. T. et al. [17] 28 85
Haroon et al. 24 73.5
score compared to international literature is possibly due
to cases with diverse age groups, with different patholo-
gies. So far no study has been published from our part of
the world describing their progress in musculoskeltal-
oncology. This may well be related to paucity of re-
sources as well as specialized centers in the same field in
our region .
5. Conclusion
Large soft tissue defects are the usual endpoint of wide
surgical resections and coverage of those defects is es-
sential. To overcome the fear of inadequate margins, one
must not be afraid of the resultant wound size. It is im-
perative to have multidisciplinary team approach for the
treatment of musculoskeletal tumor, especially when
aiming for limb salvage with resultant functional limb.
Development of sarcoma service demands high quality
centers equipped with trained staff and resources for the
management of cases and postoperative rehabilitation.
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