Received: 5 October 2019 | Accepted: 22 December 2019

DOI: 10.1002/jso.25830

RESEARCH ARTICLE

Complications after thigh sarcoma resection

Sarah M. Elswick MD1 | Daniel A. Curiel MD1 | Peter Wu MD1 |

Arya Akhavan MD2 | Vanessa E. Molinar MD1 | Anita T. Mohan MBBS1 |
Frank H. Sim MD3 | Jorys Martinez‐Jorge MD1 | Michel Saint‐Cyr MD1
1
Division of Plastic Surgery, Mayo Clinic,
Rochester, Minnesota Abstract
2
Division of Plastic Surgery, Mayo Clinic Background and Objectives: Standard treatment for extremity sarcoma is limb‐
School of Medicine, Rochester, Minnesota
sparing surgery often with radiation, but complications occur frequently. We sought
3
Department of Orthopedic Surgery, Mayo
Clinic, Rochester, Minnesota to determine factors predictive of wound complications after thigh sarcoma resection
and reconstruction while analyzing trends over time.
Correspondence
Jorys Martinez‐Jorge, MD, 200 First St SW, Methods: We reviewed all thigh defects requiring plastic surgeon reconstruction
Rochester, MN 55905. following sarcoma resection at our institution from 1997 to 2014. Patient
Email: MartinezJorge.Jorys@mayo.edu
demographics, comorbidities, operative characteristics, multi‐modality therapies,
Funding information and complications were analyzed. Wound complications were: infection, dehiscence,
Center for Clinical and Translational Science,
Mayo Clinic, Grant/Award Number: UL1 seroma, hematoma, or partial/total flap loss.
TR000135 Results: There were 159 thigh reconstructions followed for 30 months on average.
Eighty‐seven percent of patients underwent radiation and 42% had chemotherapy.
Almost half (49.1%) had a complication. The most common wound complication was
surgical site infection (23.3%) followed by dehiscence (19.5%), and seroma (10.7%). Less
common were partial (2.5%) or total flap loss (0.6%). Reoperation was required in 21
patients (13.2%). Tobacco use, older patient age, cardiac disease, and higher body mass
index were independently associated with wound complications. Complications trended
towards decreasing over time, but this was not statistically significant.
Conclusions: Tobacco use, cardiac disease, and higher body mass index, but not the
timing of reconstruction, appear to increase the risk of wound complications after
thigh soft tissue sarcomas resection and plastic surgery reconstruction.

KEYWORDS
lower extremity, sarcoma, surgical flaps

1 | INTRODUCTION between amputation and combined‐modality treatment with LSS.4,5

Soft tissue sarcomas (STS) are rare, encompassing less than 1% of all
malignancies.1 The American Cancer Society estimates that 12 750
2
people will be diagnosed with STS in 2019. STS are most commonly
located in the lower extremity and pelvic girdle, but can occur
anywhere in the body.3 The current treatment of choice for STS is
wide local excision, preferably limb‐sparing surgery (LSS), typically in
conjunction with radiation based on a study by Rosenberg et al in
1982 that found no difference in disease‐free or overall survival
There are numerous studies evaluating postoperative complications
after LSS, but these are mostly older studies with few specifically
focusing on the thigh, and there is a paucity of data on wound
complication rates among STS‐excision patients undergoing recon-
struction by a plastic surgeon.
STS of the lower extremity are known to be associated with more
complications than those in the upper extremity.6–19 Lower
extremity tumors tend to be larger, resulting in more disruption of
local structures 7. Moreover, studies have shown that within the

J Surg Oncol. 2020;1–7. wileyonlinelibrary.com/journal/jso © 2020 Wiley Periodicals, Inc. | 1

2 |
lower extremity, tumors within the thigh have a higher complication
7,11–13,15,16,20,21
and reoperation rate.
Our objectives were to (a) determine which factors are
associated with postoperative wound complications after thigh STS
reconstruction by plastic surgeons, and (b) determine if changes in
technology, surgical techniques, or advances in multi‐modality
therapy have altered the overall complication rates associated with
these challenging cases.
2 | MATERIALS AND METHODS
A retrospective review of all thigh STS defects managed by the
Division of Plastic Surgery at Mayo Clinic Rochester from 1997 to
2014 was completed after institutional review board approval. The
potential risk factors for complications that were assessed included
patient age, gender, comorbidities, utilization of chemoradiation
therapy, wound characteristics (including location, size, and exposure
of critical structures), and reconstructive procedure.
The wounds were categorized by anatomical location into
anterior, posterior, medial, or lateral thigh, and subdivided into
proximal, middle, or distal third based on where the majority of the
defect was located. Reconstructive procedures were classified as
primary closure, split‐thickness skin graft (STSG), local fasciocuta-
neous flap, local muscle flap, regional muscle flap, or free flap. Local
flaps were defined as flaps utilizing thigh tissue whereas regional
flaps involved tissue outside of the thigh (including abdominal,
gluteal, and leg tissue). If more than one reconstructive modality was
required, the most complex modality was defined as the primary
modality; for example, if both an STSG and regional muscle flap were
used, the muscle flap was considered the primary reconstructive
modality. Descriptive statistics are reported as number (percent) for
discrete variables and as mean (standard deviation) for continuous
variables.
Multivariate logistic regression (MLR) was performed to deter-
mine which factors and patient characteristics were associated
specifically with wound complications while statistically controlling
for the complex interplay between all factors within our model.
Wound complications (dependent variables) included infection,
wound dehiscence, hematoma, seroma, and partial or total flap loss.
Independent variables in the MLR model included: reconstruction
type (primary closure, free flap, skin graft, local fasciocutaneous flap,
local muscle/musculocutaneous flap), tumor location (anterior,
posterior, medial, or lateral), gender, preexisting comorbid condition
(cardiac disease, peripheral vascular disease, preexisting lower
extremity lymphedema, diabetes, active/past tobacco use, asthma,
chronic obstructive pulmonary disease, history of deep vein
thrombosis, renal insufficiency or failure, malnutrition, chronic
steroid use, chronic anticoagulation), tumor stage, length of hospital
stay, radiation therapy, chemotherapy, patient age, body mass index,
tumor volume, immediate vs delayed reconstruction, and exposure of
important structure during resection (nerve, blood vessel, bone).
Odds ratios with confidence intervals are reported. The alpha‐level
ELSWICK ET AL.
was set at 0.05 using two‐tailed tests for statistical significance in all
tests performed. The analysis was performed using REDCap
(Vanderbilt University, Nashville, TN) and SPSS 24.0 statistical
software (IBM, Armonk, NY).
3 | RESULTS
3.1 | Patient characteristics
In the study period, 159 patients were identified (Table 1). Fifty‐
three percent were male and 47% female. Mean patient age was 57.2
years (range 14‐94) and mean body mass index (BMI) was 28.9. In
terms of medical comorbidities, 48 patients (30.2%) were current or
former tobacco users. Eighty‐seven percent of patients had radiation
and 42% of patients received chemotherapy. Both treatment
modalities were mostly performed neoadjuvantly. The mean follows
up was 30 months with the longest follow up being 12.5 years.
3.2 | Cancer characteristics
There were 116 patients (73.0%) who presented with a new diagnosis
and 43 patients (27%) who had already had excision of their STS.
Twenty‐two patients (13.8%) had stage I disease, 46 (28.9%) had stage
II, 81 (50.9%) had stage III, 7 (4.4%) had stage IV, and staging
information was not available in three patients (1.9%). There was a
wide variety of histologic types, but the most common were malignant
fibrous histiocytoma, liposarcoma, and synovial sarcoma (Table 2). The
mean tumor dimensions were 9.9 × 6.9 × 4.8 cm. The tumors were
distributed fairly equally throughout the thigh but were most
commonly located proximally and medially.
3.3 | Operative characteristics
Most patients had immediate reconstruction (n = 136, 85.5%), but
delayed reconstruction was also common (n = 23, 14.5%). A lymph node
dissection was performed in only two patients. The primary recon-
structive technique was as follows: 24 primary closures (15%), 20 skin
grafts (13%), 13 local fasciocutaneous flap (8%), 50 local muscle flaps
(31%), 45 regional muscle flaps (28%), and 7 free flaps (4%).
The smallest defect was 7.5 cm3 and the largest was
3.
10 962 cm The mean defect size was 15.5 cm long by 9.1 cm wide
by 5.6 cm deep (area of 230 cm2 and volume of 1681 cm3). Two‐
thirds of patients had a critical structure exposed, such as a major
blood vessel, major nerve, bone, or joint (Table 3).
3.4 | Complications
In total, 49.1% of patients experienced a complication (Table 4). The
most common wound complication was surgical site infection
ELSWICK ET AL. | 3

T A B L E 1 Characteristics of patients undergoing thigh STS resection T A B L E 2 Tumor characteristics of patients undergoing thigh STS
resection
Number of Patients (except
where otherwise specified) Number of Patients
Gender (except where
Male 85 (53%) otherwise specified)
Female 74 (47%) Histology
Age, y, mean 57.2 Malignant fibrous histiocytoma 41 (25.8%)
<20 8 (5.0%) Liposarcoma 27 (17.0%)
20‐29 10 (6.3%) Synovial sarcoma 11 (6.9%)
30‐39 9 (5.7%) Chondrosarcoma 5 (3.1%)
40‐49 21 (13.2%) Rhabdomyosarcoma 3 (1.9%)
50‐59 27 (17.0%)
Osteosarcoma 3 (1.9%)
60‐69 37 (23.3%)
Angiosarcoma 2 (1.3%)
70‐79 32 (20.1%)
>80 15 (9.4%) Dermatofibrosarcoma protuberans 2 (1.3%)
Lymphangiosarcoma 0 (0.0%)
BMI (mean) 28.9
Other 65 (40.9%)
<18.5 2 (1.3%)
18.5‐25 44 (27.7%) Size of Tumor: mean (standard deviation)
Length, cm 9.9 (6.6)
25.01‐30 47 (29.6%)
Width, cm 6.9 (4.2)
30.01‐35 28 (17.6%)
Depth, cm 4.8 (3.0)
>35 29 (18.2%) Area, cm2 93.0 (110.6)
Medical comorbidities Volume, cm3 702.8 (1156.7)
Congestive heart failure or 30 (18.9%) Tumor Location
previous myocardial infarction Proximal third of thigh Total: 66 (41.5%)
Hypertension 27 (14.5%)
Anterior: 21
Diabetes 12 (7.5%)
Renal disease 11 (6.9%) Medial: 27
Peripheral vascular disease 6 (3.8%) Posterior: 8
History of DVT or venous stasis 10 (6.3%) Lateral 10
Preexisting lower extremity 12 (7.5%) Middle third of thigh Total: 44 (27.7%)
lymphedema Anterior: 12
Other cancer 17 (10.7%) Medial: 11
COPD or Asthma 11 (6.9%)
Posterior: 11
Connective tissue disease 1 (0.6%)
Cirrhosis 1 (0.6%) Lateral 10
Malnutritiona 5 (3.1%) Distal third of thigh Total: 49 (40.8%)
Chronic steroid use 2 (1.3%) Anterior: 11
Chronic anticoagulation 16 (10.1%) Medial: 15
Tobacco use (current or former) 48 (30.2%) Posterior: 9
Radiation Lateral 14
None 21 (13.2%) Abbreviation: STS, soft tissue sarcomas.
Preoperative only 85 (53.5%)
Preoperative and intraoperative 34 (21.4%)
Preoperative and Postoperative 11 (6.9%)
Intraoperative only 1 (0.6%)
Table 5 shows that on multivariate analysis, factors that
Intraoperative and Postoperative 1 (0.6%)
Postoperative 6 (3.8%) independently predicted a higher risk of wound complications
included tobacco use, cardiac disease, older patient age, and higher
Chemotherapy
None 92 (57.9%) BMI. Female gender and lateral tumor location were associated with
Preoperative only 51 (32.1%) lower risk of wound complications. Specifically, higher risk of wound
Postoperative 9 (5.7%)
Preoperative and postoperative 7 (4.4%) infection was associated with tobacco use (OR, 8.706, CI, 1.544‐
49.073), older age (OR, 1.056, CI, 1.001‐1.114), and higher BMI (OR,
Abbreviations: BMI, body mass index; DVT: deep vein thrombosis; STS,
soft tissue sarcomas. 1.159, CI, 1.010‐1.330). Higher risk of wound dehiscence was
a
Prealbumin <15 or albumin < 3. associated with cardiac disease (OR, 8.592, CI, 1.111‐66.470).

(23.3%), followed by dehiscence (19.5%), and seroma (10.7%). 4 | D I S C U SS I O N

Infrequent wound complications included hematoma (3.1%), partial
flap loss (2.5%), and total flap loss (0.6%). Revision surgery was
required in 21 patients (13.2%, Figures 1–3). There was a trend
approaching significance with all complications decreasing over time
(Figure 4).
LSS is the standard of care for lower extremity STS. Advances in surgical
techniques, radiation technology, and chemotherapy have helped make
LSS an even more viable treatment option. Many publications have
assessed the outcomes after surgery for STS in the extremities, but few
4 | ELSWICK ET AL.

T A B L E 3 Wound characteristics after thigh STS resection

Number (%)
Width of defect, cm
1‐5 22 (16.8%)
5.1‐10 56 (42.7%)
10.1‐15 32 (24.4%)
15.1‐20 19 (14.5%)
>20 2 (1.5%)
Not available 28
Surface area of defect, cm2
0‐100 39 (29.8%)
100.1‐200 37 (28.2%)
200.1‐300 23 (17.6%)
300.1‐400 11 (8.4%)
400.1‐500 8 (6.1%)
>500 13 (9.9%)
Not available 28
F I G U R E 1 Intra‐operative photo of a 67‐year‐old male with
Structure exposed neoadjuvant radiation therapy after resection of a right posterior
None 59 (37.1%) mid‐thigh sarcoma located in the biceps femoris muscle. The sciatic
Any critical structure 100(62.9%) nerve was exposed in the base of the wound, so a semimembranosus
Major blood vessel 24 (15.1%) flap was advanced to cover the defect. On postoperative day 16 the
Major nerve 12 (7.5%) patient developed a seroma/hematoma that required evacuation in
Bone or joint 22 (13.8%)
the operating room. About 3.5 weeks postoperatively the patient's
Blood vessel and nerve 20 (12.6%)
incision dehisced, thought to be secondary to radiation. He was
Blood vessel and bone 5 (3.1%)
taken to the operating room the following day for irrigation and
Nerve and bone 6 (3.8%)
debridement. He underwent serial irrigations and debridements
Blood vessel, nerve, and bone 11 (6.9%)
[Color figure can be viewed at wileyonlinelibrary.com]
Abbreviation: STS, soft tissue sarcoma.

have specifically addressed those in the thigh. We present one of the who underwent LSS and adjuvant radiation between 1982 and 2002.10
largest such cohorts of patients who have undergone reconstruction after Five year complications included reoperation for wound complications
thigh STS resection by a plastic surgeon. (9% of patients), edema (13%), joint stiffness (12%), nerve damage
The only publication to date that specifically addresses thigh STS is (8%), and bone fractures (7%). Vessel resection (P < .0001), wound
a retrospective review by Memorial Sloan‐Kettering with 255 patients reoperation (P = .01), and edema (P = .005) were significantly higher for
medial‐compartment tumors, whereas periosteal stripping or bone
T A B L E 4 Reconstructive complications after thigh STS resection resection was more common in the anterior compartment tumors
and reconstruction (P = .005) and nerve damage in posterior‐compartment tumors
Complication n % (P < .001).10 We found that lateral tumor location was associated with
Any 78 49.1 a lower rate of wound complications in our multivariate regression.
Wound Rimner et al10 found that tumors resected from the medial
Surgical site infection 37 23.3 compartment of the thigh had a higher rate of postoperative edema
Wound dehiscence 31 19.5
and nerve damage because most venous and lymphatic drainage run in
Seroma 17 10.7
this compartment. Our finding of a lower likelihood of infection and
Hematoma 5 3.1
Partial flap loss 4 2.5 dehiscence in the lateral compartment is likely also related to the
Total flap loss 1 0.6 relatively lower concentration of veins and lymphatics compared to
All others the medial compartment; less edema in the surgical site facilitates
Lymphedema 18 11.3 wound healing and improves perfusion, thus decreasing the potential
Limited range of motion or weakness 18 11.3
Hernia 9 5.7 for infection and dehiscence.
Pathologic fracture or prophylactic 8 5.0 Numerous retrospective reviews have assessed postoperative
hardware complications in patients with lower extremity LSS for STS and have
DVT on operated side 3 1.9
Vascular problem 2 1.3 found an overall complication rate of 22% to 45%.7,12–14,16,18,20–26 In
Pressure/decubitus ulcer 1 0.6 the thigh, this range is 28% to 54%.12,18–20,27,28 Specific complica-
Acute limb ischemia on operated side 0 0
Revision surgery 21 13.2 tions include wound dehiscence (10.5%‐16.7%), infection (4.0%‐26%),
Death 26 16.4 seroma (2.7%‐10.5%), hematoma (1%‐11%), persistent drainage
Multiple complications 33 20.8
(0.7%), skin graft breakdown (0.5%), skin necrosis (10.0%‐16.7%),
Total patients 159 100.0 edema (0.7%‐42.5%), fracture (2%‐5%), joint stiffness (7%), nerve
Abbreviations: DVT, deep vein thrombosis; STS, soft tissue sarcoma. damage (4%), and deep vein thrombosis (33.3%).9,18,20,23–25,29–32
ELSWICK ET AL. | 5

F I G U R E 2 Reconstruction of the patient in Figure 1 after dehiscence. (From top, left to right) A, Preoperative view showing defect on the posterior
thigh. B, Dissected rectus femoris flap. C, Medial view of tunnel dissected in the adductors medial to the femur. D, Anterolateral view showing retractors
in the tunnel E‐H, Tunneling of the rectus femoris muscle through the tunnel. I‐J, Insetting of the rectus femoris muscle into the defect. K, The exposed
muscle was covered with a split‐thickness skin graft 4 days later [Color figure can be viewed at wileyonlinelibrary.com]

These studies have included heterogeneous patient populations;
some have combined all STS together regardless of the upper or lower
extremity or have not specified the location or compartment within the
extremity where the tumor is located. Others have excluded patients
who have not received radiation or only received a certain type of
radiation therapy and many do not specify the type of reconstruction
that was performed, include only certain types of reconstruction, or
include or exclude patients based on who performed the reconstruc-
tion. Moreover, many of these studies look at the patient cohort as LSS
was becoming more prevalent; advances in treatment may have made

F I G U R E 3 (Left to right) Anterior (A)

and posterior (B) postoperative pictures
approximately three months after initial
sarcoma resection [Color figure can be
viewed at wileyonlinelibrary.com]
6 | ELSWICK ET AL.

wound complication occurrence on multivariate analysis. Not

surprisingly, we found that tobacco use can increase the risk of
wound infection and seroma. Cardiac disease can increase the risk of
wound dehiscence, potentially due to lower extremity swelling
causing increased tension at the incision site or perhaps poorer
perfusion leading to suboptimal wound healing.
The weaknesses of this study include its retrospective nature and
small sample size. In addition, there is a great deal of heterogeneity in
the patient population, multi‐modality therapies, tumor character-
istics, and types of reconstruction. This makes a comparison of
certain groups difficult as there can be multiple confounding
variables present in our patient population.

FIGURE 4 Percentage of patients with complications by year

some of these results obsolete. Although the complication rates in this
study are similar to these prior studies, we did observe a trend towards
lower rates of complications over time, but this was not statistically
significant. It could be that the increased use of LSS, improvements in
reconstructive technique, refinements in radiotherapy, and new or
improved chemotherapeutic regimens, may be leading to better
treatment outcomes for STS patients. This study may have been
underpowered to detect a statistically significant trend in complication
rates over time.
Risk factors for postoperative complications have been examined
and results are variable but include patient age, sex, and comorbid-
ities; tobacco use; tumor size, grade, and anatomic location (including
proximity to the skin surface); type and timing of reconstruction;
radiation factors (type, timing, dose, size of radiation field); bone
manipulation; vessel resection; and history of acute complica-
tions.6,7,10–13,15–18,20–22,25,27,28,31,33–37 Interestingly, we found that
the timing of reconstruction was not associated with wound
complication occurrence on multivariate analysis. It could be that
the timing of reconstruction may not have an influence on the
likelihood of experiencing wound complications, but further research
is needed. We also found that radiation therapy did not predict
5 | CO NCL USIONS
Thigh STS defects are prone to complications. The complication rates
in our patient population are similar to historical values, but
complication rates may be decreasing over time. Future studies
may examine larger patient populations to determine if current
treatment modalities have improved the complication rate for STS
patients. Tobacco cessation, medical cardiac optimization, and weight
loss may all help to reduce wound complications after STS excision
and reconstruction.
AC KNO WL EDG M EN TS
REDCap database at our institution is funded through the Center for
Clinical and Translational Science grant support (UL1 TR000135).
D A TA AV A I L A B I L I TY S T A T E M E N T
Research data are not shared.
ORCI D
Daniel A. Curiel http://orcid.org/0000-0002-2624-6936

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How to cite this article: Elswick SM, Curiel DA, Wu P, et al.
Complications after thigh sarcoma resection. J Surg Oncol.
2020;1–7. https://doi.org/10.1002/jso.25830