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J Hand Microsurg
DOI: 10.1055/s-0042-1751278
Original Article

Single-Stage Reconstruction with Innate Chimeric-Free Fibula Flap in Limb-Preserving Excision of Upper Limb Sarcomas

Thalaivirithan Margabandu Balakrishnan
1   Department of Plastic, Reconstructive, and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu, India
,
Srividya Madhurbootheswaran
1   Department of Plastic, Reconstructive, and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu, India
,
Jaganmohan Janardhanam
1   Department of Plastic, Reconstructive, and Faciomaxillary Surgery, Madras Medical College, Chennai, Tamil Nadu, India
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Funding None.
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Abstract

Introduction The limb-preserving excision is the standard of care in upper limb sarcoma management, but the resulting complex composite defects are exacting the expertise of the reconstructive surgeons. This study was done to evaluate a novel single-stage reconstruction of these defects using an innate chimeric-free fibula flap (a nonfabricated, anatomically available multiple tissue components harvested on independent perforators arising from the same peroneal source vessel).

Patients and Methods Twenty patients (16 male/4 female) with an average age of 29.5 years with upper extremity sarcoma (Enneking IIA/IIB) were treated by wide local excision and innate chimeric-free fibula flap reconstruction from March 2012 to March 2020. All the patients were followed for an average period of 18.3 months. At the end of the follow-up, the outcome was assessed by musculoskeletal tumor score (MSTS).

Results The flow-through flap was done in five patients. Muscle-tendon unit defects were reconstructed with a vascularized peroneus longus muscle-tendon unit in 15 patients. Nerve gap reconstruction using vascularized superficial peroneal nerve was done in eight patients. All patients had a segmental defect in the appendicular skeleton that was reconstructed with the vascularized fibular strut component. Soleus chimeric muscle component was used as a void filler and for covering the hardware in seven patients. The average size of the chimeric cutaneous component paddle was 30.7 cm2. The average length of fibula used for reconstruction was 16.6 cm. All flaps survived well, facilitating good hand function at the end of the follow-up. The average outcome score as per the MSTS was 22 (p = 0.035).

Conclusion The innate chimeric-free fibula flap provides all tissue components facilitating a good functional outcome. The advantage is the restoration of a functional hand in a single-stage reconstruction.

Keywords

limb-preserving surgery - perforator flap - chimeric fibula flap - upper limb sarcoma


Publication History

Article published online:
21 October 2022

© 2022. Society of Indian Hand Surgery & Microsurgeons. All rights reserved.

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  • References

  • 1 Drake DB. Reconstruction for limb-sparing procedures in soft-tissue sarcomas of the extremities. Clin Plast Surg 1995; 22 (01) 123-128
    CrossrefPubMedSearch in Google Scholar
  • 2 Terek RM. Tumors of the elbow and forearm. Hand Clin 1994; 10 (03) 543-551
    CrossrefPubMedSearch in Google Scholar
  • 3 Brennan MF, Casper ES, Harrison LB, Shiu MH, Gaynor J, Hajdu SI. The role of multimodality therapy in soft-tissue sarcoma. Ann Surg 1991; 214 (03) 328-336 , discussion 336–338
    CrossrefPubMedSearch in Google Scholar
  • 4 Lucattelli E, Lusetti IL, Cipriani F. et al. Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review. J Plast Reconstr Aesthet Surg
    CrossrefPubMed
  • 5 Bach AD, Kopp J, Stark GB, Horch RE. The versatility of the free osteocutaneous fibula flap in the reconstruction of extremities after sarcoma resection. World J Surg Oncol 2004; 2: 22 . Published 2004 Jul 1
    CrossrefPubMedSearch in Google Scholar
  • 6 Steinau HU, Büttemeyer R, Vogt P, Hussmann J, Hebebrand D. Limb salvage and reconstructive procedures in soft tissue sarcomas of the extremities. Recent Results Cancer Res 1995; 138: 31-39
    CrossrefPubMedSearch in Google Scholar
  • 7 Rosenthal HG, Terek RM, Lane JM. Management of extremity soft-tissue sarcomas. Clin Orthop Relat Res 1993; ; (289): 66-72
    PubMedSearch in Google Scholar
  • 8 Nichter LS, Menendez LR. Reconstructive considerations for limb salvage surgery. Orthop Clin North Am 1993; 24 (03) 511-521
    CrossrefPubMedSearch in Google Scholar
  • 9 Nigst H. [Soft tissue tumors of the hand]. Orthopade 1988; 17 (02) 209-222
    PubMedSearch in Google Scholar
  • 10 Aboulafia AJ, Malawer MM. Surgical management of pelvic and extremity osteosarcoma. Cancer 1993; 71 (10) , Suppl): 3358-3366
    CrossrefPubMedSearch in Google Scholar
  • 11 Choong PF, Sim FH. Limb-sparing surgery for bone tumors: new developments. Semin Surg Oncol 1997; 13 (01) 64-69
    CrossrefPubMedSearch in Google Scholar
  • 12 Mankin HJ, Doppelt SH, Sullivan TR, Tomford WW. Osteoarticular and intercalary allograft transplantation in the management of malignant tumors of bone. Cancer 1982; 50 (04) 613-630
    CrossrefPubMedSearch in Google Scholar
  • 13 Mankin HJ, Gebhardt MC, Tomford WW. The use of frozen cadaveric allografts in the management of patients with bone tumors of the extremities. Orthop Clin North Am 1987; 18 (02) 275-289
    CrossrefPubMedSearch in Google Scholar
  • 14 Enneking WF, Spanier SS, Malawer MM. The effect of the anatomic setting on the results of surgical procedures for soft parts sarcoma of the thigh. Cancer 1981; 47 (05) 1005-1022
    CrossrefPubMedSearch in Google Scholar
  • 15 Gugenheim Jr JJ. The Ilizarov method. Orthopedic and soft tissue applications. Clin Plast Surg 1998; 25 (04) 567-578
    PubMedSearch in Google Scholar
  • 16 Enneking WF, Morris JL. Human autologous cortical bone transplants. Clin Orthop Relat Res 1972; 87 (87) 28-35
    PubMedSearch in Google Scholar
  • 17 Harrison DH. The osteocutaneous free fibular graft. J Bone Joint Surg Br 1986; 68 (05) 804-807
    CrossrefPubMedSearch in Google Scholar
  • 18 Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Reconstr Surg 1995; 96 (03) 585-596 , discussion 597–602
    CrossrefPubMedSearch in Google Scholar
  • 19 Takushima A, Harii K, Asato H, Nakatsuka T, Kimata Y. Mandibular reconstruction using microvascular free flaps: a statistical analysis of 178 cases. Plast Reconstr Surg 2001; 108 (06) 1555-1563
    CrossrefPubMedSearch in Google Scholar
  • 20 Newington DP, Sykes PJ. The versatility of the free fibula flap in the management of traumatic long bone defects. Injury 1991; 22 (04) 275-281
    CrossrefPubMedSearch in Google Scholar
  • 21 Thalaivirithan Margabandu B, Charan JC, Jaganmohan J. An anatomical study of vascular communications between anterior tibial and peroneal osteotomes and its clinical application in proximal hemiarthroplasty of radiocarpal joint following tumor excision. Eur J Plast Surg 2019; 42: 273-281
    CrossrefPubMedSearch in Google Scholar
  • 22 Chai YM, Wang CY, Zeng BF. et al. Peroneal artery perforator chimeric flap for reconstruction of composite defects in extremities. Microsurgery 2010; 30 (03) 199-206
    CrossrefPubMedSearch in Google Scholar
  • 23 Kuo YR, Shih HS, Chen CC. et al. Free fibula osteocutaneous flap with soleus muscle as a chimeric flap for reconstructing mandibular segmental defect after oral cancer ablation. Ann Plast Surg 2010; 64 (06) 738-742
    CrossrefPubMedSearch in Google Scholar
  • 24 Ihara K, Shigetomi M, Kawai S, Doi K, Yamamoto M. Functioning muscle transplantation after wide excision of sarcomas in the extremity. Clin Orthop Relat Res 1999; ; (358): 140-148
    PubMedSearch in Google Scholar
  • 25 Grinsell D, Di Bella C, Choong PF. Functional reconstruction of sarcoma defects utilising innervated free flaps. Sarcoma 2012; 2012: 315190
    CrossrefPubMedSearch in Google Scholar
  • 26 Mundinger GS, Prucz RB, Frassica FJ, Deune EG. Concomitant upper extremity soft tissue sarcoma limb-sparing resection and functional reconstruction: assessment of outcomes and costs of surgery. Hand (N Y) 2014; 9 (02) 196-204
    CrossrefPubMedSearch in Google Scholar
  • 27 Slump J, Hofer SOP, Ferguson PC. et al. Flap choice does not affect complication rates or functional outcomes following extremity soft tissue sarcoma reconstruction. J Plast Reconstr Aesthet Surg 2018; 71 (07) 989-996
    CrossrefPubMedSearch in Google Scholar
  • 28 Balakrishnan TM, Sivarajan N. Free Fibula flow through osteocutaneous flap in the upper extremity sarcoma reconstruction. J Evol Med Dent Sci 2015; 4 (26) 30
    PubMedSearch in Google Scholar
  • 29 Huang YC, Leong CP, Pong YP, Liu TY, Kuo YR. Functional assessment of donor-site morbidity after harvest of a fibula chimeric flap with a sheet of soleus muscle for mandibular composite defect reconstruction. Microsurgery 2012; 32 (01) 20-25
    CrossrefPubMedSearch in Google Scholar