Abstract
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The orthoplastic approach refers to an integrated evaluation of the surgical approach, the preoperative planning of surgical margins of resection, the loss of healthy tissue, the size of the resultant tissue defect, the functional defect, the impact of neoadjuvant therapies on local tissue, the patient’s comorbidities, and predicted survival in order to decide the most favorable reconstruction option for the individual patient with a sarcoma. Microsurgical techniques are an essential component of the tissue reconstruction ladder.
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The vascularity of the flap used for reconstruction does not compromise the oncological outcomes, nor does it increase local recurrence or reduce overall survival.
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Free-vascularized fibula grafts are the most common osseous flaps used for bone defect reconstruction. Adequate fixation is necessary to provide mechanical stability and to increase the rate of primary bone union.
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Soft tissue wound closure under tension results in wound failure, especially when preoperative radiation therapy is used. Flap reconstruction decreases the rate of wound healing complications, allowing for continuation of adjuvant therapies.
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Soft-tissue local flaps are frequently used to treat tissue defects with a low complication rate.
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Plastic reconstruction should be tailored to the specific needs of patients.
Introduction
Sarcomas are rare primary malignant tumors of mesodermal origin originating from mesenchymal cells (1). They are a heterogeneous group of tumors that frequently involve the musculoskeletal system (2, 3). In the current decade, the treatment of patients with a musculoskeletal malignancy (primary or metastatic) has become highly individualized and requires a multidisciplinary approach.
The mainstay of treatment for both bone and soft tissue sarcomas (STSs) is surgical resection. In the past, compartment resection or amputation was the most common type of surgery performed. However, in the last three decades, significant advances in overall treatment have allowed limb salvage in >90% of patients (4). This achievement is related to advances in histology, molecular diagnosis, imaging, chemotherapy, radiation therapy and surgical techniques. New MRI offers a detailed description of tumor constitution, anatomy and vascularity, allowing for the identification of tissues at risk and accuracy in surgical planning. The integration of adjuvant and neoadjuvant therapies improves the oncological outcome regarding overall survival and local tumor recurrence and facilitates tumor resection to negative margins, which is the goal of surgical treatment. However, extensive tumor resections produce osseous soft tissue and functional defects that must be reconstructed.
In 1993, Dr Scott Levin introduced the term orthoplastic approach. As an orthopedic surgeon with microsurgical training, he early recognized the benefits of gentle intraoperative tissue handling and timely reconstruction of bone and soft tissue defects with vascularized tissues. The benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, postoperative complications, the need for revision procedures, and improved functional outcomes (5). Although this principle has been adopted mostly for trauma patients, there is a vast field of application in sarcoma patients. Currently, plastic reconstruction ranging from simple skin grafting to complex microsurgical reconstruction is considered an essential part of sarcoma surgery (6, 7, 8, 9).
Bone malignant tumors
Common primary bone sarcomas include osteosarcoma, chondrosarcoma and Ewing sarcoma. Preoperative chemotherapy plays a significant role in osteosarcoma and Ewing sarcoma. While radiation therapy with photons is frequently delivered to Ewing sarcoma patients, it has no role in osteosarcomas. Surgical excision is the sole treatment for the majority of chondrosarcomas. The scope of surgery is to remove the bone tumor with a cuff of healthy bone and soft tissue. These tumors frequently develop in the meta-epiphyseal section of the bones; thus, resection of the tumor results in loss of joint function. These bone-articular defects can be reconstructed with osteoarticular structural grafts, but oncological-type joint prosthesis is currently favored as it allows for early mobilization and functional ROM with an acceptable complication rate (10).
Diaphyseal bone defects after tumor resection are infrequent but pose a challenging surgical situation. In the past, structural diaphyseal bone allografts were used to bridge the osseous gap with plate and screw fixation favored over intramedullary nailing (11, 12). Structural allografts are not immunogenic and provide immediate strong reconstruction. However, these grafts get revascularized only at their periphery and are thus subjected to three types of complications: nonunion, infection and fracture. The overall complication rate was about 50% (13, 14). Limb salvage after failed allograft reconstruction is challenging. Vascularized fibula grafts can be used to salvage complicated allografts (15). The most commonly used vascularized bone graft in orthopedic oncology is the free vascularized fibula graft (FVFG).
The FVFG was first used in the setting of tumor surgery by Weiland et al. Taylor et al. described the vascular anatomy of FVFG, which is based on the peroneal artery (16, 17). However, surgeons should be aware that in 1.6% of patients, the anterior tibial artery is absent, precluding harvesting the fibula with the peroneal artery (18). The FVFG can be harvested with a skin paddle based on septal perforators at the middle to distal third of the fibula, or with the muscle belly of the flexor hallucis longus to reconstruct soft tissue defects simultaneously. The graft can be osteotomized while preserving the periosteal supply of the two segments, and reshaped and fixed with small plates and screws to a double barrel or an angular configuration. FVFG can be used for reconstruction of diaphyseal defects of the long bones, jaw, pelvis or spine after tumor resection, either alone or with an allograft. The skeletal reconstruction with the FVFG can be done primarily with tumor resection or in a second stage using a temporary spacer, usually hand made by PMMA.
Capana et al. developed a hybrid type of fixation composed of a structural allograft (to provide initial mechanical stability) and an FVFG to provide the biological benefit of vascularity (11). Two techniques have been described: On-lay and In-lay techniques. In the On-lay technique, the fibula graft is fixed on the surface of the allograft (Fig. 1). In the In-lay technique, the FVFG is inserted within the medullary canal. This can be done either through a bone window on the surface of the allograft or after preparation of the medullary canal with reaming, the FVFG is dragged within the medullary canal, and the vascular peroneal pedicle comes out through a hole on the surface of the allograft (19, 20).
A 30 year-old man was treated for femur diaphysis osteosarcoma with pre-op chemotherapy and tumor resection. Intraoperative image of FVFG harvesting. The fibula was osteotomized distally and proximally. (A) The peroneal artery is attached to the fibula. (B) FVFG with a vascular pedicle (white arrow). (C) Femur allograft. A segment of the diaphysis was used as intercalary graft. (D) CT image obtained 2 years postoperatively. The allograft was fixed using a lateral plate and screws. Two small plates (3.5 mm) were placed anteriorly to provide rotational stability and compression. FVFG was placed medially and fixed with screws using the On-lay technique. A perforator from the deep femoral artery was used for anastomosis. Both allograft and FVFG healed well.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0062
A significant advantage of FVFG is its ability to undergo hypertrophy under load, which enhances its long-term stability and function (12). Complications of FVFG include nonunion, stress fractures and fractures. Initial union rates are approximately 80% within 6 months, reaching nearly 100% following additional interventions, such as bone grafting or plate fixation. The initial stability of fixation seems to play a significant role in reducing the nonunion rate (12). Stress fractures (15–25% of cases), usually encountered with lower limb reconstructions where FVFGs were used as single grafts (without a structural allograft) (21, 22). Typically, stress fractures occur after bone union before hypertrophy of the fibula occurs. However, stress fractures usually heal conservatively with protected weight-bearing, sometimes promoting graft hypertrophy. True fractures of FVFG can occur around plate fixation after trauma and usually heal with revision osteosynthesis and bone grafting (Fig. 2). Overall, the Campana technique provides durable reconstruction with high Musculoskeletal Tumor Society (MSTS) scores (21, 23).
(A) Radiograph of a 10 year-old boy with a malignant vascular tumor of the radius after local recurrence. (B) FVFG reconstruction. Fixation with two plates (3.5 mm). Hypertrophy of the graft and remodeling at the osteotomy sites to the size of the host radius. (C) X-ray 1.5 years post-op, fracture of the FVFG around the proximal screw of the distal plate, after a fall playing football. The fracture was treated with revision of the osteosynthesis with a longer plate and bone grafting.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0062
In selected cases, particularly tibial defects, fibula grafts can be transferred while preserving their original vascular supply (pedicled transfer), thereby avoiding arterial anastomosis. Pedicled transfers yield outcomes comparable to those of free flaps, significantly reducing the operative time and morbidity associated with contralateral leg harvesting (23). This method is ideal for smaller defects (less than 12 cm) when anatomical conditions permit.
Another interesting application of FVFG is the use as a growing graft in children. The fibula is harvested with its fibula head, including the proximal growth plate. Although the fibula graft can be harvested with the peroneal artery, the viability of the proximal physis is not ensured. It is the recurrent arterial branch from the anterior tibial artery that is mostly responsible for blood supply to the proximal fibula growth plate. Innocenti et al. based on the cadaveric study by Taylor et al. described the surgical technique of harvesting a vascularized proximal epiphysis–diaphysis of the fibula, based on the anterior tibial artery as the feeding vessel (24, 25). After transfer, the epiphysis maintains approximately 80% of its growth potential (24). The ideal choice of FVFG as a growing graft is in children with proximal humerus or distal radius tumors (Fig. 3). A slip of the biceps femoris tendon attached to the fibula head can be included in these cases to facilitate reconstruction without jeopardizing ligamentous stability of the knee (Fig. 2). Long-plate fixation is useful for bone healing and the prevention of graft fractures.
(A) 5.5 year-old boy diagnosed with osteosarcoma of the proximal humerus. The patient received 3 cycles of pre-op chemotherapy. After tumor resection, a FVFG with proximal physis was harvested. (B) A slip of the biceps femoris tendon attached to the fibula head was included. (C) Intra-op image showing very small vessels toward the proximal fibular physis (white arrow). Peroneal nerve is indicated by the red arrow. End-to-side anastomosis of the peroneal artery to the brachial artery. Fixation of the fibula graft to the distal humerus with two plates and screws (3.5mm). The biceps tendon was used for suspension of the fibula from the acromion. Bone union was achieved 6 months later. Although shoulder ROM is quite limited, the boy is able to use the elbow and wrist in daily activities.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0062
Although amputation is necessary in unique cases, vascularized tissue can be used to augment the length of the amputated stump for optimal prosthesis use and function. These techniques include fillet flaps harvested from the amputated part (the ‘spare parts’ concept) and tibial turn-up plasty for femur reconstruction (26, 27).
Soft tissue tumors
The cornerstone of treatment for STS is tumor resection to negative margins (28). Chemotherapy and radiation can be delivered either preoperatively as neoadjuvant therapies or postoperatively as adjuvant therapies. Although wide resection margins are desirable, a negative resection margin of 1 mm plus radiation therapy is considered adequate (29). Currently, the rate of tumor resection and limb salvage is >90%. Resection of STSs frequently produces large tissue defects that must be reconstructed. Neo-adjuvant therapies, particularly preoperative radiation, have an adverse effect on local tissues by causing fibrosis, tissue mobility, impairing vascularity and reducing tissue healing ability. A nomogram based on age, BMI, tumor location and timing of radiation can be utilized to predict patients at high risk of developing major wound healing complications (30). Tension-free closure is essential to avoid major wound-healing complications that require further surgical procedures. Barwick et al. documented that flap reconstruction after neoadjuvant radio-therapy/hyperthermia and subsequent tumor resection has reduced the rate of wound healing complications from 61 to 31% (31). Kontogeorgakos et al. in a study of patients with undifferentiated STSs, reported 17% major wound complications and almost 50% of the patients eventually required a rotational or free flap for wound closure (32). All complications were related to preoperative radiotherapy and 90% of them involved the lower limbs. Wound breakdown was associated with infection in 50% of the cases (32).
Immediate, well-vascularized soft tissue coverage is fundamental to prevent wound complications. Prompt flap coverage of surgical defects significantly lowers the infection risk and improves healing, minimizes complications particularly in previously irradiated fields and avoids delaying other postoperative therapy (9, 33, 34, 35). However, the use of vascularized flaps does not always overcome the issue of wound healing problems after preoperative radiation therapy, as the radiated field is less well-vascularized and the molecular milieu of the field microenvironment is altered (7, 36).
In cases of uncertainty of tumor resection margins, temporary VAC closure of the wound can be performed, followed by plastic reconstruction in a second stage (37). Multiple flap reconstruction options exist, ranging from local tissue rearrangement and skin grafting to local rotational and pedicle flaps or free flap transfers (Fig. 4). There are no significant outcome differences among flap types, as long as the flap adequately meets the needs of the defect (34). The selection of the flap type is based on the size of the defect and the anatomy. Latissimus dorsi, anterolateral thigh, gracilis, radial forearm, tensor fascia lata, rectus abdominis and keystone type flaps are frequently utilized (Fig. 5) (8, 38).
A 50 year-old man developed a local recurrence of grade 2 soft tissue fibrosarcoma at the radial and dorsal aspect of the R wrist. (A) MRI T1 axial image of the mass. The patient received preoperative radiation therapy and a month later underwent tumor excision to negative margins. (B) Appearance of the wrist hand after radiation. (C) Intraoperative image of the tumor dissection. Tendons to the thumb are preserved. (D) Reverse radial forearm flap with an additional large vein included because of previous radiation. A skin graft was used for donor site coverage. (E) Six months postoperatively, with uncomplicated wound healing and preserved hand function.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0062
A 60 year-old woman underwent unplanned excision of high-grade STS of the left tibia with extensive microscopic positive margins (R1). Two months later, the patient underwent a new wide excision followed by radiation therapy 6 weeks postoperatively. (A) Design of the tissue resection around the old incision based on preoperative MRI. (B) Design of keystone flap size. (C) Vertical muscular perforator extending to the deep fascia and skin (black arrow). (D) Tension-free wound closure.
Citation: EFORT Open Reviews 10, 6; 10.1530/EOR-2025-0062
In a recent study, 211 patients with locally advanced or recurrent STSs were treated in the context of oncoplastic surgery (39). Amputation was avoided in 10% of the patients and all patients achieved RO-R1. Flap reconstruction was necessary in 42% of patients, a free flap was used in 20% and the reoperation rate was 15.7% (39).
Flap reconstruction seems to be much more frequent after unplanned STS excision (40, 41). Currently, the common practice after unplanned excisions is re-excision of the tumor bed, with local radiation therapy frequently delivered postoperatively (40, 42). Residual tumor is found in an average of 50% of reported cases and the presence of residual disease is an adverse prognostic factor (40).
In a systematic review of the orthoplastic approach in adult lower extremity STS, a local rotational or pedicled flap was sufficient in approximately one-third of cases, but free flaps were indispensable for extensive or distal defects (8). Revision surgery was required in 21% of patients and the limb salvage rate was 93.4%.
Flap complications include thrombosis of the arterial anastomosis, venous congestion and partial or complete flap necrosis. Many authors suggest anastomosing flap-feeding vessels to vessels outside the irradiated field (43). However, the feasibility of this method depends on the flap vessel length. It is important to perform arterial anastomosis using arteries with good flow intra-operatively. In cases with heavy previous irradiation, it may be useful to perform a CT angiography study to trace arteries with good caliber for anastomosis. Overall, soft tissue reconstruction success is high (flap survival >90%, flap loss approximately 5%), underscoring the reliability of microsurgical flaps in limb salvage (8).
The orthoplastic approach, except for the plastic reconstruction of soft tissue defects, also applies to nerve and vessel reconstruction. Lymphatic-venous anastomosis for treatment of extremity after cancer treatment is a recent surgical advancement with growing applications (44). Although major nerves and vessels are usually spared during sarcoma resection, excision of these tissues requires reconstruction to restore extremity function and limb salvage. In a study by Hauguel et al., 2.15% of patients treated for sarcoma had vascular reconstruction and 62% had a musculocutaneous flap (45). However, there was a 33% infection rate and the reoperation rate was 38% at 1 month.
More than two major nerves are considered an indication for amputation; however, one major nerve resection can be reconstructed with primary nerve cable grafts, nerve transfers or tendon transfers. When tendon transfers are insufficient, free functional muscle transfers (FFMT) become necessary in order to restore joint mobility.
Nerve reconstruction is considered essential when major motor nerves are sacrificed using nerve grafting or nerve transfer techniques. Success rates after nerve grafting depend on gap length and patient age, with older age adversely affecting outcomes (46). Nerve transfers, involving direct coaptation of a healthy nerve fascicle to the distal target nerve, can bypass damaged nerve segments, reduce regeneration time and potentially improve outcomes. Jawad et al. reported notable success rates in nerve transfers, with 82% achieving ≥M4 motor strength in upper-limb transfers compared to only 33% in the lower limbs. Sensory nerve transfers universally restored the protective sensation (47).
Aggregated data from Martin et al. indicate that nerve reconstruction is generally beneficial: approximately 77% of patients regained at least anti-gravity muscle strength (M3) after nerve repairs and 85% regained protective sensation. Functional recovery was more reliable in the upper extremities, whereas lower-limb motor recovery remained challenging, usually necessitating additional reconstructive strategies such as tendon transfers for functional improvement. Importantly, nerve reconstructions did not negatively impact oncological outcomes or the ability to administer adjuvant therapies, although preoperative radiation slightly complicated surgical procedures (46, 48).
Regarding FFMT, Kobayashi et al. have described four prerequisites necessary for flaps to succeed in joint mobility restoration (49): i) the joint in question must have retained a functional range of motion; ii) the joint must remain stable; iii) the dimensions, power and excursion of the transposed muscle must be similar to those of the resected muscle; iv) there must be local availability of functional arteries, veins and nerve motor branches.
Innocenti et al. reported excellent limb salvage and functional outcomes with LD transfers in quadriceps reconstructions, noting 73% good-to-excellent MSTS scores (50). Grinsell et al. similarly, demonstrated successful one-stage innervated FFMT (mostly LD and gracilis) in sarcoma cases, with 14 of 22 patients achieving full range of motion and nearly all reaching strong muscle strength (M4 or M5) (51). The functional outcomes were high, averaging 84% for the lower extremities and 71% for the upper extremities. A meta-analysis reinforced these findings, showing mean postoperative muscle strength around Medical Research Council (MRC) grade 3.8, with very low flap failure rates (0.8%) (52). Notably, FFMT efficacy remains high even after chemotherapy or radiotherapy (46).
Conclusion
Successful limb salvage after musculoskeletal tumor resection requires both skeletal and soft tissue reconstruction. The orthoplastic approach is an integrated part of the surgical strategy for adult and pediatric patients with musculoskeletal malignancies. Lessons learned from trauma surgery have greatly influenced orthoplastic oncology practice. Close collaboration between the orthopedic oncology surgeon and the surgeon who will perform plastic reconstruction enables more aggressive tumor resection, efficient immediate tissue reconstruction and improved limb salvage outcomes. Ideally, an orthopedic oncology surgeon with microsurgery skills would design and perform sarcoma resection and bone and soft tissue reconstruction. However, it is important to understand that sarcoma patients differ from those with tissue loss due to trauma or infection. Sarcoma patients may have several comorbidities, nutritional status is frequently poor and adjuvant therapies frequently have a systemic impact and adverse effects on local tissue. Flap reconstruction is necessary to decrease wound-healing complications and infection rates. The development of such complications may delay further medical treatment. The extent of plastic reconstruction should be balanced between what the patient needs and what the patient can tolerate surgically within the context of overall treatment and survival prognosis.
ICMJE Statement of Interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work reported.
Funding Statement
This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
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