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One-Stage Functional Composite Reconstruction of Limb-Sparing Sarcoma Resections
John T. Stranix, MD1, Z-Hye Lee, MD1, Gretl Lam, BS1, Timothy Rapp, MD2, Pierre B. Saadeh, MD1.
1Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA, 2Department of Orthopedic Surgery, New York University Langone Medical Center, New York, NY, USA.

Purpose: Innervated muscle transfer can improve functional outcomes after extensive limb-sparing sarcoma resections. We report our experience using composite anterolateral thigh (ALT) flaps with plicated iliotibial band (ITB) for static stability and, motorized vastus lateralis (VL) for functional reconstruction of large oncologic extremity defects.
Methods: Retrospective chart review identified four patients who underwent limb-sparing sarcoma resection with immediate functional reconstruction. Patient demographics, treatment, and outcomes were examined.
Results: Outcomes shown in Table 1. Follow-up ranged from 14 to 36 months, all patients demonstrated VL motor innervation by six months. At 12 months, motor strength ranged from 2-4/5, active range of motion was 25-92% of normal, and MSTS scores were between 21-26/30.
Conclusions: The composite ALT/VL flap demonstrated a number of advantages for functional reconstruction of limb-sparing sarcoma resections: 1. Generous soft tissue for coverage, long pedicle length, and large caliber vessels. 2. VL meets the functional requirements for ambulation. 3. ITB allows for in-line ligament/tendon reconstruction 4. ITB provides static musculoskeletal stabilization. 5. Minimal donor site morbidity and avoids sacrificing trunk muscles important in patient transfer. 6. Does not require intraoperative repositioning for flap harvest allowing a two-team approach that minimizes operative time. Limb-sparing techniques for upper and lower extremity sarcomas continue to evolve. Our experience has validated the ALT/ITB/VL free flap as an excellent option for one-stage functional reconstruction of large limb defects.
PatientDefectFlap componentsRecipient Strength% normal AROMDonor site morbidityAmbulateReturn to workMSTS score
Case 1Anterior Compartment Leg (16cm length, en-bloc resection)

Tibialis anterior

EHL

EDB

Peroneus longus

Tibia periosteum

ALT, 20x6cm skin paddle

Split vastus lateralis

ITB
Ankle Dorsiflexion
4/5
Ankle - 75%NYY26
Case 2Anterior Compartment Leg (22cm length, en-bloc resection)

Tibialis anterior

EHL

EDB

Peroneus longus

Deep peroneal vessels

Tibia periosteum/cortex

ALT, 16x5cm skin paddle

Split vastus lateralis

ITB
Ankle Dorsiflexion
2/5
Ankle - 25%NY*Y21
Case 3Anterior Compartment Thigh (40cm length, en-bloc resection)

Vastus medialis

Rectus femoris

Vastus lateralis

Vastus intermedius

TFL and ITB

Feumr periosteum

ALT, 35x15cm skin paddle

Entire vastus lateralis

ITB

TFL
Knee
Extension
3/5
Knee - 56%NYN23
Case 4Distal Dorsal Forearm
(15cm length, en-bloc resection)

APL, EPB, ECRL, ECRB, EPL. EDC, EDM, ECU tendons

EIP muscle/tendon

TFCC, DRUJ

Dorsal periosteum radius/ulna

ALT, 16x5cm skin paddle

ITB

TFL
Wrist/MCP/PIP Extension
4/5
Wrist - 53%
MCP - 92%
PIP - 80%
NN/AY23


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