Enrico Martin

199 Functional reconstructions in extremity STS which are not restricted to patients with multimodal therapy. Reconstructions are most commonly used after resection of a complete muscle group. The type of reconstruction depends mainly on the defect size and location. While large muscles in proximal extremities will need larger muscle transfers to restore function, more distal defects often require tendon repair by transfer or grafting. Nerve reconstructions using grafts or transfers are also possible in selected cases, yet have rarely been described. Such reconstructions are especially of interest in distal extremities to restore both motor and sensory function. Reconstructions in STS As limb salvage surgery has emerged as standard of care over the past decades and reconstructive possibilities have increased, an increasing amount of extremity STS patients survive with salvaged limbs. However, in a few cases resection of neurovascular bundles and/or complete muscle compartments is inevitable. 19 Depending on location and extent of muscle resection different degrees of disability will arise. Unfortunately, almost no studies report on the difference in functionality between patients undergoing a resection for STS only and patients that undergo functional reconstruction alongside resection. One study showed that in lower extremity STS receiving functional reconstructions had improved function. 18 Moreover, it was shown that albeit slightly longer operative times and length of hospital stay, functional reconstructions added up to be cost-effective. 18 Selection of ideal candidates is however important when considering functional reconstructions preoperatively. Resection of many muscles and tendons and even some nerves do not result in significant functional deficits. For instance in upper leg STS, only resection of three or four heads of the quadriceps muscle or the complete hamstring compartment will result in a considerable impairment as remaining muscles are not able to fully compensate for the resected muscle. 16,33 However, few cases in this study that have poor muscle function because of a ‘failed’ reconstruction, do show that MSTS scores are lower compared to their ‘successful’ counterparts and more commonly require postoperative use of braces. Reconstruction of the sciatic nerve also remains a topic of debate. Whereas some authors do not advocate restoring it, 43,44 others do recommend it. 40,41,45 Indeed, recovery of motor function should not be anticipated, especially of the peroneal compartments, 46 but studies included in this review do show that protective sensation of the foot can be acquired within little over a year. 40,41 Sural nerve grafts are commonly used because of their length, easy harvest, and low donor site morbidity as they generally only supply sensation to a part of the lateral foot and lower leg. 47 However in nerve reconstructions of large gaps, higher patient age should be considered as a contraindication because of its notorious negative effect on nerve regeneration. 48 The use of postoperative radiotherapy should on the other hand not necessarily be considered as a hard contraindication for nerve reconstruction, as it may not significantly affect functional outcomes. 49 However, nerve reconstruction itself may be complicated by preoperative radiotherapy which should be considered when planning a treatment plan. Timing 8