SOFT-TISSUE MANAGEMENT WITH IMMEDIATE FREE FLAP TRANSFER IN SEGMENTAL PROSTHETIC REPLACEMENT OF PROXIMAL TIBIA SARCOMAS ERHAN SO ¨ NMEZ, M.D., Ph.D., HALDUN ONURALP KAMBUROG ˇ LU, M.D. FEBOPRAS, * AL _ I EMRE AKSU, M.D., SERDAR NAZ _ IF NASIR, M.D., MUSTAFA KU ¨ RS  AT EVRENOS, M.D., TUNC ¸S  AFAK, M.D. and ABDULLAH KEC ¸ _ IK, M.D. Knee reconstruction with endoprosthesis after tumor resection is accepted as superior when compared with the other methods. But some- times soft tissue reconstruction would be a challenging problem in this way of treatment. Five patients who were operated for tumor resec- tion in this location, followed by reconstruction were presented with their one-year post operative results. Four latissimus dorsi and one rectus abdominis myocutaneous free flaps were used in these patients in order to manage soft tissue problems. All patients underwent chemotherapy in postoperative period. All flaps were successful in one year post operative examination. In this report we would like to stress the importance of surgical planning and soft tissue reconstruction of a specific patient population. We think that large musculocuta- neous flaps such as latissimus dorsi and rectus abdominis musculocutaneous flaps should be preferred in soft tissue reconstruction of knee region after tumor resection followed by prosthetic replacement. Additionally, this way of treatment is superior when compared to the other methods in order to prevent complications such as prosthesis exposure or infection. V V C 2011 Wiley Periodicals, Inc. Microsurgery 31:620–627, 2011. Distal femur and proximal tibia are the two most com- mon locations for primary bone sarcomas. 1 These sarco- mas can be treated either by above-knee amputation or limb sparing surgeries which were accepted as the gold standard method in last twenty years with the develop- ment of new chemotherapeutics. 2,3 Limb sparing surgeries are superior to amputation in terms of functional and cos- metic results. 4,5 These surgeries would be performed as resection plus arthrodesis, resection plus allograft, resec- tion plus composite allograft prostheses or resection plus modular/custom made endoprosthesis. Knee reconstruc- tion with endoprosthesis after tumor resection has numer- ous advantages such as easy applicability and better func- tional results. 6–9 Most of the sarcomas in this location extend to the surrounding soft tissues which have to be removed with a safety zone. Segmental knee prostheses which are used after extra-articular resections are produced larger than the conventional knee arthroplasty prostheses in order to avoid breakage and to compensate the lack of extensor mechanism’s stability. 1 As a result of this, wide tissue defects would occur around these mega-prostheses. Soft tissue management around these prostheses becomes the major determinant of success in limb salvage proce- dures. 1,10 Two different indications are present for free flap transfer after total knee arthroplasty. First one is the com- plication management indication which means impaired wound healing after implantation of prosthesis. 11–15 Sec- ond one is the prophylactic indication, which is valid in case of possible soft tissue insufficiency. 1,16–19 However, to the best of our knowledge, there are not too much se- ries regarding the second indication in literature. That is because a free flap transfer is rarely indicated in total knee arthroplasty and should only be considered for defects which cannot be covered by a pedicled (such as, medial gastrocnemius) flap. On the other hand, total knee arthroplasty following malignant tumor resection, almost always needs a free flap because of the mega tumor knee prosthesis replacement. In this report, we present our experiences of five patients that we used free flaps for both indications in the knee region after tumor resection and prosthetic replacement. PATIENTS AND METHODS Five patients aged between 13 and 37 (mean 19, four males, one female) with proximal tibia sarcomas were treated with extra articular tumor resection, followed by modular tumor-knee prostheses placement and coverage with free flaps in a year. All tumor resections were per- formed by orthopedic surgeons under pneumatic tourni- quet. Size of the defects ranges between 10 3 9 cm 2 and 19 3 10 cm 2 . Four latissimus dorsi and a rectus abdomi- nis musculocutaneous flaps were used in these patients for soft tissue reconstruction. The mean time for free flap elevation and inset was 4 hours. Anastomoses were per- formed either in an end to end or end to side fashion to the popliteal, anterior tibial, or posterior tibial arteries (Table 1). Postoperative monitoring was performed with direct observation of the capillary refill of the skin island. All Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe Uni- versity Faculty of Medicine, Ankara/Turkey *Correspondence to: Haldun O. Kamburog ˇ lu, MD, FEBOPRAS, Hacettepe U ¨ niversitesi Tıp Faku ¨ltesi, Plastik ve Rekonstru ¨ ktif Cerrahi A.D, Sıhhiye, Ankara, 06100 Turkey. E-mail: halonka@yahoo.com Received 17 February 2011; Revision accepted 1 June 2011; Accepted 2 June 2011 Published online 14 September 2011 in Wiley Online Library (wileyonlinelibrary. com). DOI 10.1002/micr.20937 V V C 2011 Wiley Periodicals, Inc.