Lower limb salvage in patients older than 75 years old affected of soft tissue sarcoma: beyond the limits

Microsurgical procedures were initially believed to be feasible only in younger patients. On the one hand, operative times may be prolonged, and on the other, older patients usually present with other comorbidities. However, without the option of microsurgical reconstructive procedures, the only curative treatment for patients with bone and soft tissue sarcomas in the lower extremity is limb amputation. This was a retrospective observational study of two cohorts of patients (group A, > 75 years old, n = 20; and group B, < 75 years old, n = 21) to compare their outcomes after lower limb salvage surgery. Selection criteria included all patients who underwent free flap reconstruction after sarcoma resection in the lower limb between 2017 and 2019. Exclusion criteria included smoking, severe comorbidities, inability to ambulate, or inadequate vessels in the preoperative image studies. Length of stay, complications, and rates of flap failure, recurrence, and amputations were compared. Average age, BMI, and presence of other comorbidities for groups A and B were 80 and 61 years old, 26 and 24 kg/m2, and 50 and 45%, respectively. Most patients (53%) had leg defects and were reconstructed with an ALT flap (60%) anastomosed to the anterior tibial artery (60%). Flap failure was observed in one group A patient. The average surgical time was 9 h. The patients followed 10 days of total bed rest and a dangling protocol was started on day 11. The mean hospital stay was 16 days and patients underwent physical therapy afterward. Postoperative surgical and medical complications in groups A and B occurred in 7/20 and 2/21, and 5/20 and 5/21 patients (25%), respectively. Age or ASA status had no effect on the incidence of complications. Radiotherapy was given postoperatively in all patients. At 1-year follow-up, all patients were alive; 27% had a recurrence or metastatic disease. The amputation rate was 25% and 0% in groups A and B, and was the only variable that reached statistical significance (p = 0.021). Based on our findings, limb salvage surgery can be performed successfully in selected old patients with lower limb sarcomas. It should be considered as a treatment option in this group of patients as it offers a safe alternative to amputation with an acceptable risk of complications, good flap success rates, and functional outcomes. Level of evidence: Level III, therapeutic; risk/prognostic study.