MANAGEMENT OF OSTEOSARCOMA THROUGH THE

COMBINATION OF ANTEROLATERAL THIGH FREE FLAP

TRANSFER AND TOTAL KNEE JOINT REPLACEMENT

Abstract
The treatment of osteosarcoma requires a combination of different methods.
In the past, surgeries to treat operations for osteosarcoma involved amputation, but
now they have become more preservative conservative with prosthetic
replacement. the replacement of the prosthesis. To reduce the incidence of
complications, it is essential to consider suitable and adequate soft tissue coverage.
In our report, we discuss the cases of four patients who underwent surgery to resect
osteosarcoma of the upper and lower head of the tibia and femur, respectively, and
were given knee joint prostheses. We chose the ALT free-flap as a suitable
material to cover the defect and the prosthesis. The flap width ranged from 4.5 to
10 cm, and the flap length ranged from 11 to 21 cm. Four flaps were used for the
surgery, two of which were fasciocutaneous, and the other two were
musculocutaneous. All flaps were well-supplied with had good blood supply and
there were no complications were reported. Preservative Conservative surgery for
osteosarcoma has is becoming increasingly popular, particularly for bone or joint
replacement. The free ALT flaps offer many advantages when it comes to
reconstructing the soft tissue defect and covering the prosthesis. These benefits
include a reliable blood supply, abundant harvested tissue, and the ability to resist
resistance to infection. The lower donor site morbidity of ALT free-flap makes it a
more favorable choice for reconstruction after joint replacement.

4. DISCUSSION
 Osteosarcoma is a type of cancer that commonly affects children during
puberty. In the past, surgery was often required to amputation of the limb affected
by osteosarcoma, which could have serious consequences on the physical and
mental development of the patient. However, scientific and technological advances
have decreased the number of amputations. Limb preservation surgery has become
increasingly popular and is now performed in more than 80% of bone cancer cases
in developed countries. In Vietnam, the number of limb-preserving surgeries for
bone cancer removal is also on the rise [3]. Limb preservation in osteosarcoma
patients is possible with good treatment outcomes when combining multiple
treatment modalities. Currently, the option of first limb amputation is only offered
in cases where the tumor has invaded major blood vessels, nerves, bones, or joints
when a safe resection margin cannot be guaranteed. High-risk patients whose limbs
cannot be preserved because of the size and location of the tumor tumor size and
tumor location should consider preoperative radiotherapy and then re-evaluate
reassess the possibility of limb preservation [4]. After a surgical procedure to
removal an of the entire tumor, it is necessary to reconstruct the bones and joints
with materials to maintain the limb function. Wei Zhu et al. concluded that joint
replacement is a safe and effective method for tumors located at the distal end of
the bone that have spread to the joints [5]. Levasic studied 8,343 patients who
underwent joint replacement patients over a 22 year period and the concluded was
that the risk of cancer in patients who have undergone joint replacement patients
was is comparable to that of the general population, indicating suggesting that joint
replacement does not increase the risk of cancer [6]. However, some have
suggested opinions are that reconstructing the hard tissue with prostheses increases
the risk of complications, especially complications related to infection and material
exposure [7]. In 2018, Cécile Philandrianos reported three clinical cases in which
surgery to remove the lower quarter of the femur due to osteosarcoma was replaced
with a prosthesis, but the infection had to be removed [8]. Jenny Fabiola López's
statistics from 2006 to 2013 showed that 109 patients had 43 of 109 lower limb
sarcoma, and 12 of 109 patients had osteosarcoma. Of Among the 35 patients using
prostheses, five patients had severe infections and three of them had to have the
material removed [9].
Local and regional flaps close the knee, such as gastrocnemius flaps,
retrograde pedicled ALT flaps, and soleus muscle flaps, are chosen by many
authors for knee reconstruction. The choice of flap for the coverage needs to
consider the joint's must take into account the range of motion to ensure enough
tissue is required for the defect [4]. In cases where adjuvant radiotherapy is
applied, it can result in skin damage, especially in grafted skin areas, and can delay
the healing process. The Local and regional flaps have limitations in both length
and width. The skin on the distal part of the limb is relatively thin and not easily
obtainable in large sizes. Additionally, the tumor often damages the lymphatic
system, so using a flap on the same damaged limb can increase the risk of
lymphedema. The pedicled fasciocutaneous flap, such as the retrograde ALT or the
gastrocnemius muscle flap, also presents some disadvantages. It has a short venous
return that can easily result in lead to necrosis of the distal end, and the flap pedicle
position is sometimes too high, which does not ensure complete coverage of the
lesion [8].
The advantage of the free flap is that it is very suitable for treating
complicated injuries due to material exposure. Due to many previous interventions,
local muscle flaps are often difficult to apply and need to be larger to cover
exposed material areas. The free flap has the advantage of 360-degree coverage of
the entire defect, thereby enhancing blood supply to the area, thus having a high
ability to preserve materials and limbs. An abundant blood supply will reduce the
infection rate and ischemia of the material's surface tissue [10]. The ALT flap has
many advantages: it covers large lesions, the flap can be thinned, and it can be
folded to ensure the desired knee position. The vascular pedicle is thick and long
enough to allow flexible microsurgical anastomosis. Flap contraction occurs very
rarely. The lower donor site morbidities are especially advantageous compared to
other microsurgical flaps, such as the DIEP flap and the latissimus dorsi flap. We
utilized the ALT flap in all of our cases, with one case serving as a salvage option
after failure of the previous pedicle flap. failed. The results demonstrated the safety
and effectiveness of the ALT-free flap. Thanks to its With the ability to provide a
large and flexible flap area, a secure blood supply, and reasonable material
coverage, our patients can begin exercising early, resulting in good functional
recovery. function.
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Figure Legends:

Fig:1: A 23-year-old female diagnosed with right femur osteosarcoma. (A): CT

image of the tumor of the lower end of the femur. (B): Soft tissue necrosis based
on the twin muscle flap used to cover the knee defect. (C): The free ALT flap is
21x7cm in size with a 7cm vascular pedicle. (D): The flap pedicle is anastomosed
to the popliteal artery branch, which results in intraoperative results. (E). Donor
site closure. (F): Results after three months
Fig 2: A 22-year-old male patient was diagnosed with osteosarcoma of the right
upper tibia. (A): X-ray image of the cancer mass. (B): The proximal tibia and
surrounding skin are removed. (C): The prosthetic joint is replaced. (D): The right
ALT flap measuring 13x6 cm is harvested with a 5cm vascular pedicle. (E).
Results after two months. (F). X-ray of the knee joint after surgery