Enrico Martin

225 Nerve reconstructions in extremity STS neoadjuvant radiotherapy administration. To date, many nerve transfers have been proposed in the literature, most commonly in upper extremity lesions. 24,71,72 But nerve transfers in the leg are also possible in certain cases. 73 In case nerve transfers are not preferred or not a viable option, grafting procedures are possible. Traditionally autografts are used and depending on the caliber of the resected nerve sural nerve grafts can be used as single strands or as cable grafts, but in smaller nerves such as digital nerves the posterior interosseous nerve, medial antebrachial cutaneous nerve, or LABCN may be used depending on ease of harvest and surgical preference. In rare cases of short defects nerve conduits can have a potential role as well, avoiding the need of a donor nerve and thus avoiding donor site infections, hematomas, and a sensory deficit. 74 However, because of the need for wide margins, larger defects are more common and in case of minimal nerve involvement the possibility of epineural dissection still remains the preferred option. In larger defects however, autografts have superior outcomes. 75 Decellularized nerve grafts may also play a role, especially in cases of large defects and insufficient autologous grafts. 76 Strengths and limitations As only a small of amount of cases have been described in literature; this study is inherently subdued to limitations. As patient characteristics, treatment modalities, and outcome measures used varied widely across studies, direct comparisons of reconstruction outcomes and the effect of multimodal treatment were impaired. Also, no study has yet been able to study functional outcome differences between comparable patients who did and did not undergo nerve reconstruction, which makes interpretability of the additional benefit difficult. Additionally, as nerves regenerate slowly, adequate follow-up is essential to truly observe final outcomes. This may especially be of importance in proximal defect reconstruction, such as sciatic nerve reconstruction, of which some cases had less than 12 months follow-up. Overall however, this study does show that nerve reconstructions can be successful after extremity soft tissue sarcoma resections. Reconstruction of sensation in the hand and foot is possible and important for good functional extremities. Yet surgical teams should always consider patient’s age, anticipated tumor defect, life expectancy, smoking, and diabetes for the success of a nerve reconstruction. In case fast recovery of function is needed, tendon transfers should also be considered. 77 Large defects will likely also need additional muscle for recovery of muscle function. Future studies should be stimulated to use both objective outcome measures such as MRC grades adjacent to more subjective outcome measures such as MSTS, DASH, or the PROMIS-extremity. To effectively consider the additional value of functional reconstructions and the reconstruction of nerve defects specifically, patients should be stratified from other LSS patients and amputees from large STS databases. 9