J Orthop Sci (2000) 5:555–560 Limb salvage in lower-extremity sarcomas and technical deta about vascular reconstruction Stefano Bonardelli 1 , Franco Nodari 1 , Roberto Maffeis 1 , Vincenzo Ippolito 2 , Mauro Saccalani 2 , Luca Lussardi 1 , and Stefano Maria Giulini 1 1 Department of Surgery, University of Brescia, Brescia, Italy 2 Center for Orthopedic Oncology, Civil General Hospital P.le Spedali Civili 1, 25100 Brescia, Italy rules originally established by Enneking. 1 The femoral bundle may be completely surrounded by tumor tissue: in such instances, any attempt to free the vessels would result in an “intralesional” procedure, with a subsequent 90%–100% risk of local recurrence for a high-grade sarcoma. In most patients, however, the tumor growing in one of the neighboring muscles may get very close to the vessel walls; when the imaging shows a thin layer of normal tissue in the vessel-tumor interface,preoperative radiation therapy may help in clearing this tissue of tumor cells. A longitudinal split of the vessel adventitia, made along the side opposite to the tumor, may allow freeing-up of the vessel, leaving the adventitia on the tumor bed as a “compartmental barrier”, using ad- equate techniques of subadventitial vascular isolation. In those patients in whom the surgeon feels that this cannot be done without risking tumor contamination, it is much safer to resect the vessels (Fig. 1). We can say, therefore, that vascular resection is indicated whenever it would be impossible to achieve a “wide” margin with- out resecting the vessels. The aim is to avoid the amputa- tion which was considered to be necessary in the past. 5 In this article, we present our experience with vascular resection in patients with soft-tissue sarcomas of the thigh and discuss the main controversies regarding indi- cations and surgical techniques, thus providing an addi- tion to the limited number of studies published, each of which includes from 3 to 21 cases (see Tables 1, 2). Patients and methods From 1995 to 1999, seven patients with soft-tissue sarco- mas of the thigh and tumor involvement of the neuro- vascularbundle underwent limb-sparing procedures with curative intent (see Table 2). There were five men and two women, with a mean age of 56.7 years (range, 30–77 years). Five patients had been referred with pre- viously untreated lesions, while two patients presented Abstract Vascular surgery may allow limb salvage when a sarcoma of the lower limb involves the main vascular bundle. We present our experience and describe the techniques which have been employed for such surgery. From October 1995 to April 1999, vascular surgery procedures were employed in seven patients with sarcomas of the thigh: two complete subadventitia dissections of the main vascular trunks, four artery replacements (two polytetrafluoroethylene [PTFE] grafts and two autologous saphenous grafts), and five venous reconstructions (all with autogenous saphenous graft: three substitutions; two distal transpositions with one external rigid support at the anastomosis). Clinical and instrumental (sonogram, computed tomography [CT] scan, echodoppler) follow-up was carried out at 3, 6, and then every 12 months after surgery (mean, 25 months; range, 6–53 months). Opera- tive mortality and morbidity were nil. All the grafts were patent (one arterial thrombosis was successfully treated on the first postoperative day). The functional result was good in six patients and fair in one. Two patients died, 24 and 13 months after surgery, with disseminated disease, but had no local recurrence. Five patients are alive and disease-free. Vascular techniques allow limb salvage with en-bloc resection of sarco- mas of the thigh involving the main vessels. Venous recon- structions are indicated after removal of both the superficial and deep femoral veins. We suggest limiting the number of anastomoses (two transpositions in our series) and using ex- ternal rigid support in those patients with a small saphenous vein graft (one patient in our series). Key words Sarcoma · Limb salvage · Venous reconstructions Introduction The therapy of sarcomas of the lower limbs requires a “wide” resection which must be performed following the Offprint requests to: S. Bonardelli, Via Aperta 21, 25075 Nave (Brescia), Italy Received: February 7, 2000 / Accepted: July 21, 2000