Limb salvage remains a major objective in contemporary management of
bony and soft tissue sarcomas of the pelvis and lower extremities [
Seven consecutive patients with complicated wounds secondary to resection of pelvic
and proximal lower extremity musculoskeletal sarcoma were managed with modified VRAM flaps between
2002–2005. The median
age of the patients in this series at the time of surgery was 21 years (range
15–49) and included 5 men and 2 women. The modifications included VRAM flap
with lateral and tongue-like extension design of the skin paddle (5 cases) or a
delayed extended VRAM flap (2 cases). All the patients have been treated with a
multidisciplinary approach; the management of osteosarcoma patients (2 pelvic,
2 proximal femur) included a 4-month course of neoadjavant chemotherapy
followed by resection of the primary tumor and postoperative 3-month course of chemotherapy;
while chondrosarcoma patients (3 pelvic) were offered surgical resection only.
The complications, which necessitated management by the plastic and
reconstructive surgeons, included infection and wound dehiscence with ultimate
exposure of metal prosthesis (4 patients) and necrosis of thigh flaps (3
patients). The median interval duration between the primary operation and the
reconstructive procedure for the complicated wounds was 16 days (range: 13–36).
All patients underwent thorough clinical assessment, adequate debridment and
irrigation of the wounds, followed by immediate coverage of the resultant
defects (median size
This technique was used to cover exposed metal plates due
to wound breakdown after osteosarcomas resection of proximal femur where length
of the flap was predominantly required than its width. An ipsilateral
parasternal skin paddle was designed 10 cm cephalic to the costal margin and 2 cm from the lateral sternal edge. The pinch test, originally described by
Taylor et al. [
(a) A two-week picture after delay procedure (surgical and vascular delay) for extended inferiorly based VRAM flap. The arrow points to line of demarcation between nonperfused and augmented perfused skin in the parasternal fasciocutaneous extension of the VRAM flap. This extension provided additional predictable length of 7 cm for coverage of exposed plate femur after osteosarcoma resection of the proximal femur. (b) Intraoperative picture after harvesting of VRAM flap and debridement of necrotic thigh flap. The VRAM extension marked by the suture markings of the delay procedure provides the extra length avoiding tension and providing durable coverage. (c) Postoperative picture 3 months during chemotherapy course showing complete survival of the flap providing stable coverage and complete healing of the donor site.
This technique was used in cases after resection of chondrosarcomas and osteosarcomas of the pelvis, which necessitated the development of large subcutaneous thigh flap to allow adequate exposure and vascular exploration to achieve adequate oncological resection. Extensive full-thickness thigh flap necrosis occurred in these patients which necessitated adequate debridement and coverage of the resultant defect utilizing a contralateral, laterally oriented VRAM with a tongue-like skin extension. The contralateral muscle was selected due to the sacrifice of the ipsilateral inferior epigastric pedicle as part of the radicality of the primary tumor resection. The lateral orientation of the skin paddle was designed to be oblique (45°) to the longitudinal axis of the rectus muscle to provide an average extra length of 5 cm. The tongue-like extension of the skin paddle was designed throughout the whole length of the muscle tapering towards the pivot point of the flap at the entry of the inferior epigastric pedicle. The fasciomusculocutaneous component of the VRAM flap was harvested utilizing the standard technique with elevation of the laterally oriented part of the flap in the fascial plane. The origin and insertion of rectus muscle were transacted leaving the vascular pedicle as the sole tether point; this significantly increased the arc of rotation allowing more muscle mass to be transposed to the wound. Incising the skin bridge between the donor and recipient defect to lay open the tunnel connecting the recipient and the donor site followed this. The tongue-like skin extension provided the roof for opened tunnel after rotation of the flap to settle to the defect; allowing more room for the pedicle and providing coverage for the medial part of the defect.
(a) Preoperative picture showing the dimensions and design of contralateral, laterally oriented VRAM with a tongue-like extension. The arrow points to the necrotic thigh flap advocated achieving adequate oncological resection for pelvic osteosarcoma. (b) Intraoperative picture showing insetting of flap after debridment of the necrotic area. The distal muscular component of the flap fills the composite defect which helps resist infection in this potentially infected area. (c) Intraoperative picture showing coverage of the defect with application of a split thickness graft on the remaining muscular bed. The arrow points to the tongue-like skin extension which avoids tension on the vascular pedicle especially after dividing the origin and insertion and ensures adequate perfusion to the distal portion of the flap. (d) Late postoperative picture 6 months after completion of chemotherapy course showing complete survival of the flap with long-term durability and complete take of the graft.
In all patients, the donor site was closed primarily after reinforcement of the abdominal wall using an onlay prolene mesh, suction drains were used both at the recipient and donor sites. All patients were mobilized within 2 weeks postoperatively under supervision of the orthopaedic and physical therapy team. The mean duration to postoperative chemotherapy was 3 weeks. The mean follow-up period was 26 months at which patients were followed up with assessment of the oncological outcome, durability of soft tissue reconstruction, and finally assessing the functional outcome using Enneking system,
All flaps showed complete survival and healing with no ischemic events, hence providing stable coverage. Mild infection was observed in 1 patient; no haematomas were detected. All patients were ambulant with good limb functions in terms of walking and gait after adequate rehabilitation; 2 needed additional support with crutches. All patients showed good emotional acceptance; and no pain has been observed during ambulation in all patients. One patient developed incisional hernia at the donor site that required repair 1 year later; otherwise, no other donor site morbidity was noted. Another patient died of haematogenous metastatic spread after complete resection 15 months later. There was no hypertrophic scar formation or flap breakdown experienced on long-term follow-up in any of the patients.
Limb preservation has become a more realistic and
necessary goal in the management of patients with musculoskeletal sarcoma of
extremities [
The reconstructive options to provide coverage
following debridment of these complicated wounds would be local, distant flaps,
or free-tissue transfer. VRAM flaps have
been used successfully in coverage of defects of the chest wall, groin, hip,
perineal, vaginal, and gluteal regions with good functional outcomes [
The delayed phenomenon has been used for many years
to enhance functional blood flow through vasodilatation of the arterial network
and avoidance of complete vasoconstriction caused by catecholamine release, and
hence it increases the flap reliability especially in high-risk
patients [
The authors believe that these modifications will provide reliable extralength of soft tissue, which is tension free with a wider arc of rotation, better filling of dead space with well-vascularized tissue so as to resist infection, and stable coverage with good functional outcome.
Other modalities described for management of
complicated infected wounds as skin grafting or vacuum-assisted closure would
not be suitable due to the presence of dead space and exposed hardware
prosthesis after debridement [
The use of free-tissue transfer is rare in these
clinical scenarios; on the other, hand-free osteocutaneous fibular flaps were
performed for primary skeletal reconstruction after tumor extipiration of
sarcoma of the lower extremities [
In conclusion, the modified VRAM flaps would offer reliable reconstructive tools for coverage of complicated primary wound with necrosis and breakdown after radical resection of pelvic and proximal lower limb musculoskeletal sarcoma. They offer larger well-vascularized soft tissue with acceptable donor site, more durable coverage with no delay in the postoperative adjuvant therapy, good functional outcome, together with overall improvement in the survival.
The authors express their gratitude to Mr. Hisham Rashid (Lead Clinician, Consultant Surgeon King's College Hospital, London, UK) and to Mr. Jonathan Roberts (Lead Consultant Surgeon King's College Hospital, London, UK) for their valuable and careful review of this article.