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Flap Reconstruction after Resection of Lower Extremity Bone Tumors: A Secondary Analysis of the Parity Trial
Dylan K. Kim, AB, Kathleen Gu, BS, Brianna M. Peet, BS, Wakenda K Tyler, MD, Christine H. Rohde, MD MPH and Jarrod T Bogue, MD
Columbia University Irving Medical Center, New York, NY
Background: Endoprosthetic reconstruction for lower extremity bone tumors is associated with a relatively high risk of infection. Although flap reconstruction has been associated with improved postoperative outcomes after such tumor surgeries, existing literature has not comprehensively investigated its impact within large, multicenter patient cohorts with granular surgical data.
Methods: A secondary analysis of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial was conducted, incorporating 604 patients undergoing endoprosthetic reconstruction for lower extremity bone tumors. Cohorts with and without flap utilization were compared and balanced using weights derived from entropy balancing. The effect of flap reconstruction on one-year surgical site infection (SSI), reoperation, and functional outcomes as measured by the Toronto Extremity Salvage Score (TESS) was assessed with multivariable logistic regression in the balanced cohorts (p<0.05).
Results: Among the cohort of 604 patients, the overall rate of one-year SSI was 15.9%, and the overall rate of unplanned reoperation was 25.7%. Flap reconstruction was incorporated in 83 (13.7%) cases and included local muscle flaps (64, 10.4%), local fasciocutaneous flaps (12, 2.0%), and free flaps (9, 1.5%). Flap utilization was associated with tumors of the tibia, longer surgical incision, and large excisions of skin (p<0.05). After balancing cohorts, flap reconstruction was not associated with SSI (OR: 0.56, 95% CI: 0.30-1.04, p=0.068) but was independently associated with significantly lower odds of reoperation (OR: 0.46, 95% CI: 0.26-0.82, p=0.0083). Cases with flap reconstruction were associated with lower absolute risks of reoperations for soft tissue coverage (6.0% vs. 11.9%) and deep infection (18.1% vs. 27.0%). Flap reconstruction was not associated with different functional outcomes after one year (p>0.05).
Conclusion: In this secondary analysis of a randomized controlled trial, flap reconstruction was associated with factors indicating generally higher surgical risk, such as longer surgical incisions, larger excisions of skin and muscle, and longer hospital stay. Flap reconstruction independently reduced risk for reoperation in balanced cohorts. Flap coverage may prevent deep infections and hardware exposure following endoprosthetic reconstruction.
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