Enrico Martin

223 Nerve reconstructions in extremity STS without impairing local control. 53–55 In the latter case, when STS encase nerves by less than three quarters of their circumference, dissection of epineurium only suffices. However, as this means a ‘close’ margin was achieved, postoperative radiotherapy is indicated. 53–55 Nerve reconstruction versus no reconstruction in LSS Nerve reconstructions are only carried out in 0.4% of all STS patients, 19 even though nerve resections occur in 1.2-12%. 9,10,12–17 Reasons for surgeons to not reconstruct nerves may vary, including the paucity of literature of its use in ablative surgery and therefore expected outcomes, not involving reconstructive surgeons with familiarity of nerve reconstruction options in surgical planning, insufficient knowledge of the impact of neuropathic pain and insensate extremities on functionality, and the uncertainty of outcomes of nerve reconstruction when using radiotherapy and chemotherapy. Reconstruction of a sciatic nerve defect has been subject of debate in the last decades. Whereas sciatic nerve involvement of STS used to be a hard contraindication for limb salvage, because of extensive loss of both motor and sensory function, nowadays it is not. Several studies have shown that its resection without reconstruction could lead to acceptable functionality and patients prefer this over amputation. 56 As a result, many discourage reconstructing the sciatic nerve as outcomes of reconstruction were reportedly poor. Three studies included in this review do indeed show that muscle function of the lower leg will most likely not recover, but most patients will regain some protective sensation in the foot. 44,45 Three out of seven patients even had recovery of plantar foot sensation, even though follow-up of patients was less than a year in some cases, possibly underestimating final outcomes. Restoration of sensation in the foot has repeatedly been shown to reduce rates of foot ulcers in diabetic patients and thus decrease the need for amputation. 57 This is not a phenomenon reserved for diabetic feet solely, it has also been reported to have caused secondary amputation in STS as well. 13 Although restoration of motor function was not seen in the aforementioned cases, after reconstruction in traumatic patients, some did regain distal motor function, especially in children. 58 Altogether, reconstruction of the sciatic nerve may therefore be beneficial in some cases and restoration of sensation should be considered as its primary goal. Although resection of the femoral nerve without reconstruction show similar functional outcomes as sciatic nerve resections, one study showed that fractures occurred commonly as a result from loss of knee extension. 9 Therefore reconstruction of knee extension should strongly be considered. In case more than half of the quadriceps muscle is intact, reconstruction of the femoral nerve could be considered, otherwise a biceps femoris transfer or free functioning latissimus dorsi flap may recover lost function. 59–61 In STS overall, as LSS has become standard of care, functional extremities are extremities that also have sensation, especially in the hand and foot sole. While motor defects may also be reconstructed using tendon transfers or free functioning muscle transfers, sensory loss can only be compensated with nerve reconstructions. 61 Furthermore, after resection of nerves, neuropathic pain is not rare 9