Enrico Martin

224 Chapter 9 in STS. 62,63 One study reported a prevalence of 25% of surgically treated sarcomas. 63 In these patients functional outcomes were worse in these patients, with significantly lower Toronto Extremity Salvage Score (TESS) and MSTS scores. This further underlines the importance of preventing neuropathic pain as its occurrence has a disabling impact and is not limited to trauma only. Although many techniques are available to treat neuromas, nerve reconstruction is known to prevent neuropathic pain as it decreases the risk of neuroma formation, 64 which may be the reason no patient was reported to have it in this study. Multimodal treatment and nerve regeneration Although LSS is performed for functionality purposes, in STS oncologic treatment should be prioritized in almost any case. This means that clear margins are essential, but radiotherapy also remains an important in treating extremity STS. 3 The effect of multimodal treatment on the regeneration of nerves has had little attention in a clinical setting, which has made clinicians cautious when combining the two. The effect of chemotherapy on the regenerative capacity of nerves has been studied in one study in mice and did however not show any adverse effect. 65 Other preclinical studies have shown that both adjuvant as well as neoadjuvant radiotherapy do not impair function in mice after nerve reconstruction. 66–69 It is nonetheless advocated that whenever nerve reconstructions are performed in an irradiated wound bed, fibrous tissue is removed. 70 Additionally, free tissue transfers for wound coverage are commonly performed after STS resection and also form a good wound bed for nerves as they are unirradiated. This study shows that indeed functional outcome may not necessarily be impaired by multimodal treatment, nor has its timing. These findings are also supported when evaluating the success rate of neurotization in free functioning muscle transfers in extremity STS. 61 Nerve reconstruction options in extremity STS Reconstructive strategies applied in an extremity STS patient should ideally be discussed during surgical planning in a multidisciplinary setting in order to review all possible options for both the tumor ablative surgery, e.g. close margin surgery, as well as reconstructive options. Including a wide range of reconstructive options and diverse presentation of patients no one tool will suffice in STS patients and ideal reconstruction should be discussed case-by-case. However, some general rules may be taken into consideration. If the resection of a nerve seems inevitable, grafting or distal nerve transfers may restore lost function. Distal nerve transfers are increasingly being used in trauma cases, showing good functional restoration and diminishing the time of a nerve to reach its end target. 24,71 Theoretically, nerve transfers can be of great use in sarcoma surgery as well, especially in cases of proximal nerve defects such as partial plexus resections. Secondly, distal nerve transfers offer the option of providing a reconstruction outside of the operation and radiation field. This may particularly be interesting in case of an extensively scarred tissue bed due to repeat surgeries or