Enrico Martin

200 Chapter 8 of functional reconstructions is difficult, but direct reconstruction (within 2-3 weeks) seems to be preferred over a delayed surgical reconstruction. 50–53 This ensures an early start of rehabilitation, which is even more important to obtain good results after such reconstructions. 51–53 Additionally, less complications occur and fibrosis is not yet present which complicates delayed reconstructions since adequate vessels and nerves may be difficult to find. 50–53 In high-grade STS achieving clear margins may be essential before performing any type of reconstruction. Also, one must consider that nerve regeneration in FFMT and nerve reconstructions can take several months before reaching its target. 33 In contrast, tendon transfers result in immediate function restoration and could be considered in cases where early recovery is needed. 54 Nerve transfers are also increasingly used in traumatic nerve injuries and are becoming standard of care in brachial plexus surgery. 55,56 These reconstructions provide the opportunity to restore nerve function distal to the defect, thus decreasing the time to recovery. In extremity STS this may also imply reconstructing outside of possible radiation fields. Multimodal treatment and reconstruction in STS Although LSS is performed for functionality purposes, in STS oncologic treatment should of course have priority in almost any case. This means that clear margins are essential, especially in high grade STS. Studies have however shown that the early participation of a plastic surgeon can yield higher rates of clear margins if free flaps are considered at an early stage. 57,58 The effect of chemotherapy and radiotherapy in functional reconstructions has not been thoroughly investigated. Studies included in this review however showed that all but one flap survived, and generally only minor complications occurred. One study did report radiotherapy induced fractures which ultimately affected functional outcomes. 37 Another series showed no negative effect of radiotherapy on functional outcomes after biceps femoris transfer for the reconstruction of knee extension. 39 In LSS generally, multiple studies have shown that preoperative radiotherapy does not increase complications when flaps are used. 59–63 These studies are however in contrast to the trial by O’Sullivan et al. 11 and other LSS studies. 7–10 In case postoperative radiotherapy is administered, free flap surgery can facilitate early start of treatment. 64 Also, complications may possibly be diminished when flaps are used compared to no flap usage. 61,63–65 Besides, restoration of function may alleviate the need for orthoses, 33 which are difficult to wear on irradiated skin. Overall, the use of functional reconstructions does not seem to impede the use of either pre- or postoperative radiotherapy. The effects of chemotherapy are less frequently addressed in literature, but its use in LSS does not seem to increase complications regardless of sequence. 66,67 Strengths and limitations Main limitations to our study include the large heterogeneity among studies and their patients, as well as the low amount of patients treated with functional reconstructions. Direct comparison between studies and flaps used is complicated due to the different