Enrico Martin

222 Chapter 9 Tibial nerve One patient was reported to have a reconstruction of the tibial nerve at the level of the ankle. 48 A defect of the ankle and foot flexors was reconstructed with fascia lata strips, which was covered with an anterolateral thigh flap. Seven years postoperatively MSTS score was excellent (97%). Complications A total of four complications were reported, of which three were wound-related problems. 38,42,44 One patient developed wound dehiscence after a reconstruction of the RSN with an LABCN graft and the use of brachytherapy. 38 Two wound complications occurred after the reconstruction of the sciatic nerve in one study. 44 One patient developed radiation-induced hand lesions which impaired hand function. 42 No patient was reported to have developed neuropathic pain. Unfortunately, a total of three patients died within the first year after surgery due to distant metastases. 44,46 Discussion Nerve reconstructions by either grafting or transfers can aid in avoiding postoperative muscle weakness and recover loss of sensation. Nerve reconstructions after resection of soft tissue sarcomas in extremities have nevertheless had little attention in literature and are irregularly carried out. When performed they seem to be successful in a selected group of patients and the use of multimodal treatment does not seem to impair these outcomes. Success rates were however higher in upper extremity defects as opposed to lower extremity defects. Neuromas and neuropathic pain may possibly also be avoided. Preservation of nerves Before considering any nerve reconstruction, surgeons should always consider strategies to preserve nerve structures. The resection of nerves significantly decreases functional outcomes. 9,10,12–14,16,17 Adequate preoperative imaging may help surgical planning by demonstrating the extent of nerve involvement. Recently, the use of diffusion tensor imaging (DTI) has shown promising results in facilitating three-dimensional images of nerve involvement. 49 Furthermore, in the past decades several techniques have shown to significantly reduce the need for nerve resection. Neoadjuvant treatment can possibly reduce tumor size prior to surgery. Firstly, in large previously unresectable extremity sarcomas, isolated-limb perfusion (ILP) can be administered. 50,51 During this process the perfusion of an extremity is isolated and intra- arterial chemotherapy is infused, decreasing tumor size. Secondly, while neoadjuvant radiotherapy does not only have smaller long-term toxicities compared to adjuvant therapy, it may also reduce size preoperatively, especially in myxoid liposarcoma. 52 And lastly, epineural dissection has been shown effective to avoid resection of major nerves