Risk factors for significant wound complications following wide resection of extremity soft tissue sarcomas

Background: Wound complications following resection of a localized soft tissue sarcoma have been associated with lower extremity location, large tumor volume, and use of preoperative radiation. Some of these wounds, however, show the potential for healing with local wound care and nonsurgical techniques. We are unaware of any published data establishing factors associated with nonhealing wounds that ultimately are treated with local or free vascularized tissue transfer. Questions/purposes: The purpose of this study was to determine the variables associated with development of a significant wound complication defined as one that underwent a secondary procedure using local or free tissue transfer after resection of a localized soft tissue sarcoma. Methods: Using our institution's cancer center database, we identified 140 patients who underwent resection of a localized extremity soft tissue sarcoma at our institution between 1997 and 2010. Thirty-two patients were excluded who underwent immediate planned vascularized tissue transfer, along with 26 patients who did not receive radiation, and an additional three patients were excluded who were followed for less than 1 month. This left 79 patients, including 18 treated with postoperative external beam radiotherapy and 61 with preoperative external beam radiotherapy. Of patients receiving radiation treatment before surgery, 13 received no additional radiation treatment, 33 underwent intraoperative radiation with electrons (IOERT) to sites considered at high risk for local recurrence, and an additional 15 had perioperative brachytherapy. Univariate and multiple regression analyses were performed using frequency of local or free tissue transfer at 3 weeks or greater postoperatively owing to wound-related complications as a dependent variable. Results: Lower extremity location and vascular involvement were associated with use of delayed vascularized tissue coverage for wound-healing problems. Patients in this series who underwent preoperative external beam radiotherapy coupled with dose-escalated IOERT or chemotherapy had a similar rate of flap use compared with patients treated with postoperative radiation. Conclusions: Patients with tumors of the lower extremity involving major neurovascular structures and for whom radiation therapy is planned should be counseled specifically because they appear to be at increased risk for use of delayed local or free vascularized tissue transfer for a nonhealing wound following resection of a localized extremity soft tissue sarcoma. Level of Evidence: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.