Soft tissue sarcomas affecting the posterior lower leg: Surgical Tecniques and results

From 1988 to 2004 we treated 37 patients affected by a soft tissue sarcoma of the posterior lower leg. All tumors were high grade (grade 3 or 4 broders) except four. A primary procedure was performed in 18 cases; 19 patients had been operated on in other centres and came to us for re-excision after inadequate previous surgery (12 cases) or local recurrence (7 cases). Age of the patients ranged from 1 to 81 years (average 41). In 7 cases we performed a primary amputation; in the remaining 30 patients a limb-sparing procedure was the primary treatment. Histologically confirmed wide margins were achieved in all but 4 patients. In 14 case soft tissue coverage after excision required a free flap (11 latissimus dorsi, 2 parascapolaris, 1 chinese flap). In 20 patients adequate continuity of the triceps-achilles complex (adequate tendon strength and at least one muscle unit) could be mantained; in 1 patient the deep portion of the Achilles tendon was excised with the tumor and the tendon was reinforced by a flap cut in the proximal triceps aponeurosis and moved distally. In the remaining 9 cases tumor location required primary excision of the achilles tendon. Reconstruction of the tendon was performed in 7 cases: in 4 patients with an artificial tendon wrapped by an autologous fascia lata graft, in 2 patients by transposing the tibialis posterior tendon plus a peroneal tendon (in one case the peroneus longus and in one case the peroneus brevis) to the calcaneus tuberosity, in 1 patient by cutting a flap in the triceps aponeurosis and moving it distally to the calcaneus with augmentation by the peroneus brevis tendon. In all cases of achilles apparatus reconstruction a free flap was used for closure. In two patients an ankle arthrodesis was performed. Use of post-operative radiotherapy and/or brachitherapy led to wound dehiscence and Achilles tendon partial necrosis in 5 cases. In 4 of these patients we performed a salvage procedure by an anterolateral thigh fasciocutaneous flap with debridement and reinforcement of the tendon; 1 patient underwent a secondary amputation. One more patient received a secondary amputation because of local recurrence. At follow-up 8 patients had died because of the disease (at a time from the primary procedure ranging from 12 to 120 months; average 37 months); one patient had died for concomitant disease at 15 months. The remaining patients were alive at an average follow-up of 95 months (23 to 205); 20 patients were continuously disease free at latest follow-up, 7 were alive with no evidence of disease after treatment for local or distant recurrence, 1 was alive with disease (lungs). 3 patients developed a local recurrence, 13 patients presented distant metastases. Oncological and functional results of limb-sparing surgery in this difficult anatomical area are presented and discussed. Limb sparing surgery in soft tissue sarcomas of the posterior lower leg can be a functionally and oncologically effective procedure, even in cases where a complex reconstructive procedure for the achilles myotendinous complex is necessary, if adequate margins can be achieved. Particular attention has to be paid in adjuvant radiotherapy to avoid important post-treatment complications