Aims

The aim of this study was to evaluate the surgical management and outcome of patients with an acral soft-tissue sarcoma of the hand or foot.

Introduction

Our Unit has been treating large volume soft tissue sarcomas involving the sciatic nerve with epineurectomy for over a decade. The aim of this study was to quantify the functional outcome of patients who were known to have sciatic nerve involvement pre-operatively and went on to have nerve preserving surgery utilising a planned marginal excision with epineurectomy.

Deep prosthetic joint infection remains an uncommon but serious complication of total hip replacement. We reviewed 24 patients with recalcitrant hip wounds following infected total hip replacement treated with either pedicled rectus femoris or vastus lateralis muscle flaps between 1998 and 2009. The mean age of the patients was 67.4 years (42 to 86) with ten men and 14 women.

There had been a mean of four (1 to 8) previous attempts to close the wound. A total of 20 rectus femoris and five vastus lateralis flaps were used, with one of each type of flap failing and requiring further reconstruction. All patients had positive microbiology. At a mean follow-up of 47 months (9 to 128), 22 patients had a healed wound and two had a persistent sinus. The prosthesis had been retained in five patients. In the remainder it had been removed, and subsequently re-implanted in nine patients. Six patients continued to take antibiotics at final follow-up.

This series demonstrates the effectiveness of pedicled muscle flaps in healing these infected wounds. The high number of previous debridements suggests that these flaps could have been used earlier.

Introduction: Acral sarcomas present as small tumours to specialised orthopaedic services. There is a high incidence of inadequate resection compromising clinical and functional outcome.

It is advised that lumps which are greater than 5cm should be referred to a sarcoma centre for management and that small lesions cause less harm with unplanned excision.

Method: Data from the Oxford Registry was collated of all those patients with acral sarcomas who underwent surgery in a period from 1997 – 2008 at The Nuffield Orthopaedic Centre including site, size, histological subtype, of tumours, history of previous surgical excisions, staging, and functional scores.

Results: 27 patients were treated (17 foot and ankle cases, 10 hand tumours). The commonest acral lesions were synovial sarcomas (30%).

Of the hand patients 7 of the 10 patients had wide excision of the lesion with 3 an amputation. 5 of the cases were for inadequate previous excision (50%).

7 of the 17 in the foot and ankle group underwent amputation (41%) the rest wide excision. 29% of cases were for second time surgery due to inadequate previous excision.

Discussion: Our study shows that up to 50% of patients with acral tumours are undergoing further surgery due to previous inadequate excision. The belief that 5cm should be a benchmark for specialist referral should not be applied to such lesions.

Aim of Study: Assess clinical outcome and function of planned marginal excision of low grade liposarcoma of the forearm.

Material and Methods: Between 1997 and 2005 15 of 27 soft tissue sarcomas of the forearm were liposarcoma.

13 presented in the extensor compartment and 2 flexor compartment at the level of the distal radius. All presented with a painless mass. 5 patients with neurological symptoms. 4 involving the post interosseus nerve and 1 radial nerve. MRI was the diagnostic imaging technique of choice, 2 had biopsies where there was atypical imaging features.

Treatment and Results: All treated by planned marginal excision in view of proximity of neurovascular structures. The majority of tumours of the extensor compartment of the forearm were either involving or abutting the post interosseus nerve or neurovascular conduit.

All underwent planned marginal excision preserving juxtaposed peripheral nerve. There were no radial, spiral or PIN nerve palsies. One patient presented with PIN palsy had partial resolution of symptoms and function. I wound infection

Conclusion: Low grade lipoma-like liposarcomas have low metastatic potential. In the forearm a wide margin would mean ablation of critical neurological structures and planned marginal excision results in good function and to date no evidence of local recurrence at 2–9 year follow up.

Aim: To review our series of mid foot sarcomas with regard to excision of tumour, tolerance of radiotherapy and preservation of function.

Methods and results: We identified 6 patients with mid foot sarcomas treated in our unit. Synovial sarcoma was the commonest diagnosis. All the patients had stage 1 disease with no evidence of pulmonary metastases at presentation. Patients judged to have resectable tumour but preserving sufficient foot to be functional were spared amputation. They had excision of the sarcoma and immediate reconstruction using fascio-cutaneous free flaps. Complete excision was achieved in all cases. One flap was lost and repeated. In all patients, subsequent radiotherapy was well tolerated without significant complications. All patients remain disease free. All patients have returned to pre-operative functioning including walking and jogging. All except one have returned to work.

Conclusion: Patients and feet treated by wide local excision of mid foot sarcomas and reconstructed by free fascio-cutaneous flaps tolerate post-operative radio-therapy well, and return to near normal function.

Aim: To assess the functional outcomes for patients treated by limb salvage surgery for sarcomas of the upper limb and shoulder girdle.

Materials and methods: Patients who had undergone limb salvage surgery for upper limb sarcoma between 1997 and 2004 were entered into the study. The operation notes were used to obtain details of the surgery. Pathology reports were consulted to identify the type, grade and margins of the tumour. The Toronto Extremity Salvage Score (TESS) questionnaire was used to assess post-operative function, in a postal survey.

Results: A total of 62 patients were identified. Liposarcoma was most common histological diagnosis, and “low” the most common grade (27). Histologically clear margins were achieved in 28 (44%) cases, marginal in 2 (3%), incomplete in 13 (21%) and indeterminate in 20 (32%). 30% had received adjuvant radiotherapy with or without chemotherapy as indicated. A total of 48 (76%) had been treated with excision and primary closure, 7 (11%) with local flaps, and 4 (6%) with endoprostheses. 10 patients had died, and 1 was untraceable. 29 completed TESS questionnaires were returned; with an average follow-up of 33 months post-resection (range 4 to 83). 11 female (38%), 18 male (62%), with an average age at surgery of 55. The average TESS score was 77 +/−10 with a range of 18–100. For the different regions, forearm sarcomas had an average TESS of 81 +/−17, upper arm 76 +/−19 and shoulder 81 +/−14.

Discussion: Surgical excision of soft tissue tumours with limb salvage aims to balance morbidity and mortality. Upper limb amputation has greater morbidity than lower limb and thus the argument for limb salvage should be stronger. A limb-salvage procedure should be considered preferable to amputation provided oncological outcomes are not compromised, and the resulting functional outcome is worth the oncological risk. In this cohort, patients had good functional outcomes, as described by the TESS functional assessment score, with no evidence of compromised oncological outcome during the follow up period.