ABSTRACT

CORRESPONDING AUTHOR:
Dr. Sivarajan N,
# 27, Customs Colony,
V. G. P. Salai, Saidapet,
Chennai-600015.
E-mail: sivarajandr@yahoo.com

Abstract: Introduction: With the evolution of modern reconstructive methods amputations for malignant tumours of the upper limb can be prevented. Of all the methods, the free fibula is most commonly used to bridge bone gaps during limb salvage. Objective: to study the effectiveness of flow through fibula osteocutaneous flap in the reconstruction of upper extremity following oncological excision of forearm sarcomas, where both axial vessels are excised or dominant vessel is excised. Materials: This study was conducted between March 2012 to March 2013 at our institute. A total of 6 cases(4 male and 2 female) aged between 19 and 40 years with Soft tissue sarcoma of the forearm were treated with Wide Local Excision and reconstruction using flow through osteocutaneous fibula flap. Of these,4 patients had both the ulnar and radial arteries removed and in 2 patients the dominant/ codominant radial aretery was removed. The 4 patients in the first group received post op RT and the other 2 patients received post op chemotherapy. All patients were followed up for a mean period of 9 months. Results: Histopathology was varied- Spindle cell sarcoma (2pts), synoviosarcoma (2 pts), osteosarcoma (1pt) and fibrosarcoma (1pt). All the tumours were located in the distal 1/3^rd of the forearm. All the flaps survived, and all the patients had good to reasonable hand function at follow up. One patient developed pulmonary metastasis and 1 patient developed CRPS type 2. Conclusion: Amputation of the upper limb was thought to be the best approach for STS of the forearm. With the flow through flaps the vascularity and function of the hand can be maintained. Thus an irreplaceable vital organ, namely hand, can be saved with these flaps. The missing vascular conduit is reestablished and at the same time, bone and soft tissue is reconstructed.

Keywords: flow through fibula, osteocutaneous, sarcoma, limb preservation surgery.

Introduction: Advances in tumour biology understanding, improved chemotherapy and radiotherapy (neoadjuvant or adjuvant in post op treatment), ability of surgical oncologists to excise the tumour with a good margin(principle of excision without seeing the tumour) and advances in plastic surgical expertise where there is always a technique available to reconstruct any composite defect of the upper extremity have all paved the way for limb salvage surgery.¹ Oncological resections, especially in the forearm sarcomas have resulted in complex composite defects with loss of axial vessels of the hand compromising its vitality.

These defects pose challenging options for any reconstructive surgeon. To envisage vitality and function of the hand, as a part of Limb Preservation Surgery (LPS), it requires a vessel conduit to bridge the defect in the vascular continuity and at the same time it should also provide skeletal stability, muscle and tendon continuity with or without recipient nerve anastomosis and finally the skin cover.

All these requirements are effectively addressed by the flow through fibula osteocutaneous flap,² where the peroneal artery restores the vascular deficit by acting as the conduit; the fibula provides the skeletal continuity(sometimes as a single bone forearm reconstruction); the peroneus longus harvested on an independant peroneal artery perforator, provides for reconstruction of the muscle tendon deficit, if the vascularised superficial peroneal nerve fascicle is also harvested, it will facilitate functional reconstruction.The skin island is useful for both post op monitoring and reconstruction of skin defect. Thus the flow through fibula osteocutaneous flap provides an avenue for the reconstruction of all the components of complex composite sarcoma resections. The use of neoadjuvant chemotherapy and post-operative radiation adds to the locoregional disease control.^3,4

Materials: In our department, between March 2012 and March 2013 we have done 6 cases of upper extremity Sarcoma reconstruction, all involving the forearm region. Of these in 4 cases both the radial and ulnar artery segments were resected with the tumour. In the other 2 cases the ulnar artery was spared, the resected radial artery was confirmed to be the dominant/codominat vessel, producing on table hypoperfusion of the ulnar border of the hand.So in all the 6 cases we have reconstructed vascular, bony, muscle tendon and skin defect by the flow through osteocutaneous flap. We followed up all these cases for an average of 9 months. All the 6 cases had very good functional recovery of hand with no claudication or ischemic changes.

Surgical technique: Management of the patient was first discussed with the multispeciality integrated tumour board, comprising the consultants from surgical oncology, Plastic surgery, Medical oncology, Radiation therapy and occupational therapy. A consensus in the management is then arrived in the planning session for the various reconstructive options. Presence of the palmar arch is confirmed (clinical examination inclusive of Allen’s test) in all the patients. The handedness of the patient is also taken into consideration.

Preoperative work up includes routine MRI with T2 weighted images are done in all cases. In all patients after explaining the pros and cons of LPS an informed consent was taken. The ability and intelligence quotient to cooperate for post op physiotherapy and neoadjuvant chemotherapy were also assessed for careful patient selection. We do not do preoperative angiogram in the upper or lower limbs.

After the completion of the resection by the surgical oncologist, the tourniquet was removed and 20 minutes of perfusion allowed. The vitality of the hand and the defect were examined. In those patients were the oncologist was certain of resecting the tumour with both the vessels, simultaneous 2 team approach was followed. In those cases were one vessel is resected, simulataneous harvest was done, but the distal peroneal artery is not ligated until the need for a flow through flap was discerned. In the first scenario, were both vessels were resected, starighaway the distal end was prepared for anastomosis and flap is harvested.

We followed the posterolateral approach for flap harvest because it is easy to maintain the perforator to the peroneus longus in this approach. The same technique of fibula flap harvest is used except special attention is paid for harvesting proximal and distal peroneal artery with adequate length to allow tension free anastomosis at the recipient site.

Preplating was done before osteotomy to know the exact dimension of the bone segment, vascular segement, muscle tendon segment and skin paddle dimensions. Compression plated with screws was used for skeletal continuity reconstruction and K wires for wrist arthrodesis. In some cases a combination of both were used.

Peroneus longus muscle tendon unit as required for the deficit is harvested with little extra length. The order of reconstruction was bone, vessels and the musle tendon unit. The long flexor muscle mass with its intact neurovasc bundle were sutured to the proximal part of the Palmaris Longus. Distally PL tendon was weaved into FDP residuam at or proximal to Carpal Tunnel. The defect between the proximal and distal ends were bridged with peroneus tendon using nonabsorbable prolene sutures. When the extensor musle tendon gap was encountered the wrist was arthrodesised in 30 degrees extension, and wrist extensors was transferred to the EDC.

The median and ulnar nerve gaps following resection were reconstructed with vascularised nerve grafts (1 case) as and when required. Less critical nerves such as superficial branch of the radial Nerve, lateral and medial cutaneous nerves of the forearm were ignored.

The skin paddle is sized down to the defect during final closure. During the harvest of peroneus longus the dissection on the lateral side of the fibula is between periosteum and muscle to increase the 3 Dimensional positioning of muscle. The rest of the surface is harvested with little cuff of soleus, peroneus tertius and FHL muscles.

Post op Course: Hand elevation, external POP slab (with a window for skin paddle monitoring) splinting the hand in functional position. The POP slab was continued for a period of 4 weeks, after which the patient was educated about care of the insensate hand. After this passive stretching protocol for joints of the hand is started with night splinting for another 4 weeks. Active movements are encouraged in hand joints with proximal joint exercises after 8 weeks.

Of all the 6 patients, 5 flaps had no complications. 1 flap was salvaged by correction of venous thrombosis, with a vein graft. All our patients gained light touch at an average of about 4 months along with large diameter fibre pain and temperature recognition. Functional aspect of recovery was tested by 2 independant observers. All assessments were done at the end of 9 months using the MSTS scoring system.

Discussion: The treatment options for upper limb sarcomas include amputations,⁵ replantation of the remaining distal forearm/hand,^6,7 prosthesis^8.9 and Limb preservation. In our department we have established, both from the oncological aspect and as well as function/form recovery, LPS is not inferior to amputation.

LPS is a boon for sarcoma forearm patients, wherein both function and form are established. Flow through free fibula osteocutaneous flap when harvested in chimeric form i.e. the skin and muscle paddle harvested on independant perforators, but supplied by the same source vessel; provides all avenues for reconstructing the composite defect.¹⁰ Reconstructing vessel, skeletal, Nerve gaps and the soft tissue defect in one go using flow through fibula osteocutaneous chimeric flap is a technically demanding and raison d’etre to achieve the form and function of the hand. Especially when the supportive medical oncology and radiation therapy readily available limb preservation and salvage can be made a reality.^11,12 The plastic surgeons with this new armamentarium complete the last chip of the limb preservation effort.

There are many studies to support the role of preoperative CTA for the lower limb.^13,14,15 Nasaya et al in their study said that MRA is the investigation of choice for location, position of the peroneal perforators.¹⁶ On the contrary there is enough evidence to suggest that routine preoperative CTA is not requied.¹⁷ Preoperative CTA was not routinely done in our series. Peroneus Longus which is harvested as a component of chimeric free fibula octeocutaneous flap is a type II muscle.¹⁸ The major pedicle (muscle perforator) from the peroneal to artery was within 2.5cm from the single best perforator the skin paddle in all our cases.

In the first group of 4 patients, where both the forearm axial vessels were sacrificed, the simple extra anastomosis between distal peroneal artery to radial artery in the distal forearm, which takes an extra 30 minutes establishes the vascular conduit continuity and serves to preserve the limb.In the second group of 2 patients, following the extirpation of sarcoma, the presence of ulnar border ischemia in the hand, envisage the need for the flow through free fibula osteocutaneous flap.

The decision on the nerve was taken on table. It has been proved there is no difference in local or distant recurrences with epineurectomy.¹⁹ Gerrand et al technique of preservation of the nerve by planned positive margins was not followed.²⁰ In those cases where the tumour is obviously invading the nerve, we do not do neurolysis and resection/ nerve grafting is done.

Skillful assessment of the post extirpation defect in terms of skeletal defect, muscle tendon defect, skin defect and nerve gaps paves the way for fabrication of the flap. Simultaneous 2 team approach decreases the operating time. With excellent post-operative monitoring and physiotherapy regimen. All cases had good direct osteosynthesis in the proximal and distal ends with regain of protective sensation in hand, in addition to finger flexion/extension. The skin paddle required was very less. The average skeletal defect was 9.5cm. On follow up there was no evidence of claudiction, ischemic changes. However, one patient developed pulmonary metastasis and one patient CRPS type II. At 9 months follow up there were no signs of any locoregional recurrence and all the flaps had settled well.

Arai et al used the simple fibular osteocutaneous flap for limb preservation. He reported a complication rate of 56%.²¹ In comparison our complication rate of 33% was trivial and manageable. However his study was elaborate with a total of 60 cases, and our study had a small sample size of 6 cases.

Gao et al have reported vascularised bone reconstruction as a part of Limb preservation.²² None of their cases received post op radiotherapy and their complication rates were on par with us.

CONCLUSION: Sarcoma reconstruction has undergone a radical change towards preservation of the limb with the usage of the vascularised free fibula flap. The major advantage is that there is no compromise in the extent of resection. We recommend the use of the peroneus longus muscle tendon unit based on an independent perforator from the peroneal artery. The use of the peroneus muscle has improved the functional outcome in these patients.

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SS – Synovial Sarcoma.

FS – Fibro Sarcoma.

SCS – Spindle Cell Sarcoma.

OS – Osteo Sarcoma.

ES – Endothelial Sarcom

Fig. 6: Peroneus longus musculotendinous unit interposed to the flexor digitorum profundus gap and fibula proximally fixed to the radius and distally arthrodesed to extended  wrist  and proximal radial artery to peroneal artery anastomosis  done and distal peroneal vessel to radial artery anastomosis done and the venae comitantes of the peroneal artery anastomosed to the cephalic vein proximally.