Enrico Martin

246 Chapter 10 sole is feasible recovering after just more than a year. 25,26 Not only will patients have more than just a warm leg, foot ulcers and secondary amputations may be avoided, which is not a phenomenon reserved for diabetic patients. 11 However, while functional reconstructions may well provide good restoration of function, candidate selection is of utmost importance. Indeed, as some reconstructions require a long rehabilitation and as nerves only regenerate slowly, a patient’s life expectancy should be adequate for reconstructions to be purposeful. Clinical studies have shown that localized MPNSTs have a median survival of 5-8 years. 3,4,6 This is considerably longer than the 3 years, that respondents to our survey agreed upon before considering functional reconstructions. Multimodal treatment and timing of reconstruction As sarcomas commonly require the use of radiotherapy and sometimes chemotherapy, some surgeons consider this to be a contraindication for performing functional reconstructions. The effect of multimodal therapy on outcomes after functional reconstructions has however had little attention in literature. In available case series on functional reconstructions, negative effects of multimodal therapy are not evident, not even when performing nerve reconstructions. 17 Negative effects on nerve regeneration are also not seen in animal studies. 27,28 However, the use of neoadjuvant radiotherapy may complicate nerve reconstruction and fibrous tissue should ideally be removed in order to create a well vascularized wound bed. 29 As more research emerges on the use of nerve transfers in trauma patients, 30,31 their implementation in tumor surgery can be studied further. Nerve transfers can provide the opportunity to restore function outside of irradiated tumor fields and shorten the time of nerves to reach their end targets compared to nerve grafting. 30,31 The ideal timing of reconstruction also remains a topic of debate, which is reflected in this survey. As MPNSTs are high-grade sarcomas in almost any case, obtaining free margins remains crucial before performing any reconstruction. However, after obtaining these margins, direct reconstruction has shown superior results over delayed surgical reconstruction. 32–34 Early reconstruction is surgically less complex as fibrosis is not yet extensive, ameliorating nerve and vessel identification, thus decreasing possible complications. 32–34 Also, rehabilitation can be started earlier, which then may improve functional outcomes. 32–34 Neuropathic pain in MPNST Neuropathic pain, the loss of sensation in combination with paradoxal allodynia and hyperalgesia, can be highly disabling. This has shown to significantly decrease functional outcome in sarcoma patients. 21 This postoperative complication is even less studied than motor deficits. On the other hand, 25% of all sarcoma patients are reported to have at least mild neuropathic pain. 21 Supposedly, in MPNSTs this may be as high as 40% of all patients, but this has, to the authors knowledge, not been studied in patients previously. Postoperative neuropathic pain is commonly caused by neuroma formation and preventive measures may decrease rates of neuropathic pain. 35,36 A meta-analysis showed that once present, only 77% of neuroma surgeries are effective, underlining