Enrico Martin

282 Chapter 12 that both motor and sensory deficits can adequately be restored in MPNST and STS patients with lost function. Yet functional reconstructions are unfortunately still not standard of care. As highlighted in Chapter 10 , many surgeons are still hesitant towards incorporating functional reconstructions in their surgical plan and a minority of surgeons always considers the use of functional reconstructions. Chapter 10 shows that the problem is likely twofold. Firstly, surgical oncologists operate most patients, yet rarely involve reconstructive surgeons before surgical excision. This may be due to a lack of knowledge on the ability and outcomes of reversing function loss with reconstructions. Secondly, reconstructive surgeons may be too hesitant to perform the full range of reconstructive options due to a lack of knowledge on the oncological outcomes of STS and the impact of multimodal therapy on successful reconstructions. Nevertheless, both clinical and preclinical evidence do not suggest a negative impact of radiotherapy and chemotherapy on success rates of functional reconstructions. Whenever free tissue flaps are used in patients receiving radiotherapy, wound complications are minimized. 29,30 A multitude of reconstructive options are available and more options are increasingly being studied and applied in trauma cases. Selection of their use is based on numerous factors, including defect size and location, patient characteristics, functional deficits, and the need for soft tissue coverage. Yet, only nerve reconstructions and innervated skin flaps are capable of restoring sensation. Nerve transfers are increasingly being used over nerve grafting as they facilitate shorter time to reinnervation and possibly better functional outcomes. 31 Distal nerve transfers may be easier in case of irradiated wound beds and whenever a local recurrence occurs, the reconstruction is not necessarily at stake. The reconstruction of some deficits remains questionable nevertheless, including the reconstruction of sciatic nerve defects. Its resection leads to a flail and insensate distal leg and more proximally to loss of biceps femoris function as well. Only nerve reconstructions are available to reconstruct the defect, but rarely results in restoration of muscle function. 32,33 Sensation may however be regained, at least partially, and reconstructions can therefore be beneficial. As outcomes vary, it can be advocated that patients already prone to poor nerve regeneration should less likely be considered eligible for sciatic nerve reconstruction. Contrarily, younger patients, especially children, should be considered eligible for sciatic reconstructions as nerve reconstructions have significantly higher success rates. 34 Besides motor and sensory function loss, neuropathic pain can seriously affect functional status, but has had even less attention in STS literature. In any surgically treated STS, prevalence of neuropathic pain may be as high as 25%, which significantly lowers functional outcomes. 35 In Chapter 10 , surgeons reported newly formed neuropathic pain in up to 41% of surgically treated MPNST patients, yet many surgeons still do not use neuroma preventive measures. True prevalence of newly formed neuropathic pain in MPNST patients has yet to be studied which could in turn support better nerve handling techniques such as ideal neuroma preventive measures and nerve conduction testing in selected cases. Nerve reconstructions are known to considerably diminish the risk of (painful) neuroma formation which is an